
Class 






Book_^_il^.^ 



Copyright N^_ 



COPYRIGHT DEPOSIT. 



The Office Treatment Of 
Rectal Diseases 

Explained and Simplified 

Being an Exposition of the Treatment of all Those 

Diseases, both Medical and Surgical, of the 

Rectum, Anus, and Sigmoid Flexure, the 

Cure of Which May be Accomplished 

Without Surgical Anaesthesia 



BY 



RUFUSD. MASON, M.D. 

OMAHA, NEBRASKA 



PROFESSOR OF RECTAL AND PELVIC SURGERY IN THE 

JOHN A. CREIGHTON MEDICAL COLLEGE, SURGEON TO 

ST. JOSEPH HOSPITAL, MEMBER OF THE AMERICAN 

MEDICAL ASSOCIATION, MEDICAL SOCIETY OF 

THE MISSOURI VALLEY. NEBRASKA STATE 

MEDICAL SOCIETY, OMAHA MEDICAL 

SOCIETY. AMERICAN PROCTOLOGIC 

SOCIETY, ETC. 



FOURTH EDITION 



ILLUSTRATED 

THE BURTON COMPANY 

MEDICAL PUBLISHERS 

KANSAS CITY, MISSOURI 
1908. 






UBRARY of CONGRESS 
I wo CoDies Heceive* 

JUN 16 1908 

0US»/4 XXc Wu 



copyrighted i905 & i908 by 
Thb Burton Company. 

KANSAS CITY. Mo. 



The Burton Press. 



TO 

THE FAMILY PHYSICIAN 

TRIALS AND HARDSHIPS I FULLY APPRECIATE, AND WHOSE 
LABORS HAVE FOR MANY YEARS BEEN SHARED BY ME, 
THIS VOLUME IS FRATERNALLY INSCRIBED. 



PREFACE. 

It is not intended that this book shall take the 
place of larger works upon the same subject, but 
that it may be an addition to them, and cover many 
points that have been omitted. It is the result of 
many years' practical work as a specialist and teach- 
er along this line, and is a description of methods 
tried and found valuable. 

Diagnosis is discussed very briefly, merely to 
bring the malady prominently before the reader. Et- 
iology, pathology, anatomy, vague theories and ma- 
jor operations are omitted, and the work devoted 
merely to treatment, which is discussed in the most 
terse and practical manner possible. 

I have consulted freely the literature of the sub- 
ject, and have made use of such portions as seemed 
suitable for a work of this kind. 

As surgical procedures are an evolution, and the 
9 



16 RECTAL DISEASES. 

result of many minds working along the same lines, 
it is impossible to give proper credit to any one per- 
son ; for this reason names of different men who 
have written upon this subject are not mentioned ex- 
cept in rare instances. 

If any excuse were necessary for this work, I 
would only call attention to the fact that there are 
many persons who suffer severely from rectal 
troubles who fear to take chloroform and undergo 
what to them seems a serious operation, but who 
would gladly pay for cure by less severe methods. 
Most of these people could be permanently relieved 
if their doctor knew how to go about it. The object 
of this book is to tell him how. 

It is my desire that it may be received in the pro- 
fessional spirit with which it is presented. 

Omaha, Nebraska, 1901. 



PREFACE TO SECOND EDITION. 

The first edition of this book was so cordially 
received by both the professional and the medical 
press that another is necessary in less than a year 
from the time the first one was ready for delivery. 

The scope of the work has been somewhat en- 
larged, much new matter having been added, and 
some changes made in the previous text. It has also 
been more profusely illustrated. 

I wish to express my appreciation of the many 
kind words that have been received in regard to this 
little volume; it shows plainly that such a work is 
desired by the profession, and that it covers a field 
that is not encroached upon by any similar publica- 
tion. 

Omaha, Nebraska, 1902. 
II 



PREFACE TO THIRD EDITION. 

The fact that the first and second editions of this 
work have been sold in less than four years and that 
a third is now required attests the value that the pro- 
fession has placed upon it. 

The present edition has been thoroughly revised 
and much new^ matter added. While the work deals 
essentially with treatment, I have added more in the 
way of classification and diagnosis than were in the 
former editions. This has been done for the benefit 
of medical students and physicians in general prac- 
tice who do not have the time to perfect themselves 
by referring to the more elaborate works written for 
the benefit of specialists. 

I have also added some things that cannot in 
every instance be done with local anaesthesia, but 
with the ever widening field into which the different 
local anaesthetics are being used, there is but very 
little of the surgery here described but what may 
be done in this way. 

As was stated in the preface to the first edition, 
13 



14 RECTAL DISEASES. 

no attempt has been made to write an exhaustive 
treatise on rectal diseases, as there are many most 
excellent books to be had on this subject, written by 
specialists of great ability; but there is no short, 
practical, concise book suitable for the physician in 
general practice who does not see enough rectal cases 
to become familiar with them. Such a want, this 
book is intended to fill. It is also believed to be of 
great value to the student who wishes to perfect him- 
self in this work sufficiently to pass a satisfactory 
examination but does not care to take it up as a 
specialty. 

I have attempted to describe only the most eas- 
ily done and at the same time satisfactory, opera- 
tions or methods of treatment, such as I have made 
personal use of and found satisfactory. Others that 
may be equally good have been omitted as have 
also all theories and methods that have not stood 
the test of time and proof. 

Many new cuts have been added in order to more 
fully explain the text and the mechanical construc- 
tion has been considerably improved, for which I 
wish to thank the publishers. The Burton Co., who 
have shown me favors in many ways, 

Omaha, Nebraska, 1905, 



PREFACE TO FOURTH EDITION. 

It is exceedingly gratifying to both the pubHsh- 
ers and the author that the third edition of this 
work is exhausted in so short a time. 

The book has from time to time been enlarged 
until it now covers a large portion of the field of 
rectal diseases. It was the intention of the author 
when getting out the first edition f.o include only 
such operations and methods of treatment as could 
be done in the physician's office or the patient's 
home without the use of a general anaesthetic. At 
the request of many friends among the profession 
its scope has been enlarged so that it includes near- 
ly all of the diseases and methods of treatment gen- 
erally discussed in books on rectal diseases except 
major surgical operations. 

15 



i6 RECTAL DISEASES. 

The book was written primarily for the physi- 
cian in general practice rather than the specialist, 
and this fact has not been lost sight of in the pres- 
ent edition. The family doctor is the one to whom 
these sufferers first apply for relief and he should 
be prepared to diagnose their troubles and apply 
such remedies as the conditions found demand. 

Considerable new matter has been added to the 
present volume and several new cuts added. 

As was stated in the first edition of this book, 
surgical procedures and methods of treatment are 
an evolution, and the result of many minds work- 
ing along the same line. For this reason it is hard 
to give credit to any one person. However, I have 
tried to give recognition for original work done, to 
all to whom it is justly due. Unfortunately, I have 
not been given this consideration by others in all 
cases, as some of my writings have been used almost 
word for word and no credit given. 

I wish to thank the Profession for the very cor- 
dial reception given previous editions. It is my 
earnest desire that the present volume mav Drove 
of some value to all who read it. 

Omaha, Nebraska, U. S. A., 1908. 



PREFACE 
INTRODUCTION 



CONTENTS. 



CHAPTER I. 



GENERAL CONSIDERATIONS AND DIAGNOSIS 

Rectal Diseases Verv Common — Great sufferers — General 
belief in obscurity — Per cent of Cases the Average Physi- 
cian may Obtain — Equipment — ^Examination of the Pa- 
tient — Methods of Diagnosis — Symptoms — Protrusion at 
stool — Pain — Hemorrhage — Discharge — Diarrhoea — Con- 
stitutional Symp:^oms — Physical Examination — Position 
— Instrumental Examination — ^Importance of Advance 
information — Card used for Record ....27 

CHAPTER n. 

ANATOMY 

The essential points — Bones of the Pelvis — The Pelvis — 
The Muscles — Sphincter Ani — Internal Sphincter — 
Levator Ani — Coccygeus — Perinei — The Rectum — The 
Arteries — The Veins — The Nerves — The Perineum and 
Ischio — Rectal Region — The Female Perineum. 48 

CHAPTER HI. 

CONSTIPATION 
As a Symptom — Constipation due to Specific Canses — What 
is meant by constipation— Normal Bowel Movement — 

17 



i8 RECTAL DISEASES. 

"Alimentary Constipation" — Lack of residue in the bowel 
not constipation — Intestinal Indigestion — The lack of 
Fluids in Food — Training the Bowels — Physiology of 
Defecation — Other causes of Constipation — Characteris- 
tics of the Stools — Diagnosis — Treatment — Boas' Diet- 
List — Mechanical Treatment — Massage — Vibration — 
Electricity — Rectal Lavage — Exercise — Drugs. -67 

CHAPTER IV. 

FECAL IMPACTION 

Accumulation of Fecal Matter — Diarrhoea from Irritation — 
Causes — Symptoms — Diagnosis — Constipation — Treat- 
ment — Softening and Breaking up of the Masses — Re- 
moving it Mechanicall}^ — Cathartics Harmful — Injection 
of Water useless — Injection of Oxgall, of crude Petrol- 
eum, of other Mixtures — Massage — Vibration — Mechan- 
ical Methods 83 

CHAPTER V. 

RECTAL ALIMENTATION 

Early Beliefs — Nourishment by Absorption — When Rectal 
feeding becomes necessar}- — The necessit}" of great care 
and gentleness^ — Methods of Injection — Position — Care of 
Tubes — Where the Food should be deposited — The 
quantity of food — Intervals between feeding — Kind of 
foods for rectal feeding. 87 

CHAPTER VI. 

HEMORRHOIDS 

What Hemorrhoids are — Causes of Hemorrhoids — More 
frequent in men than women — Classification — External — 
Internal — Symptoms and Diagnosis — Capillary — Ven- 
ous — Thrombolic — Cutaneous or connective tissues — 
Treatment — Palliative treatment — Diet — The general 
health — Drugs — Dilatation — Divulsion — Injection method 
of treatment — Methods of operating — Formulas for injec- 
tion treatment — When the injection method should not be 
used — Other methods of cure — Operations — Electrolysis. 
91 

CHAPTER VII. 

ABSCESS 
Seat of suppuration — Pus — Results — Fistula Abscess — 



CONTENTS. 19 



Etiolog}' — Constitutional conditions — Varieties of ab- 
scess — Subcutaneous or marginal abscess — Ischio — 
Rectal abscess — Submucous abscess — Pelvi — Rectal ab- 
scess — Symptoms and diagnosis — Treatment — Post 
operative treatment. 142 

CHAPTER VIII. 

FISTULA 

Definition — Variety of Fistulas — Etiology — Location — Symp- 
toms and Diagnosis — Incomplete external Fistula — In- 
complete internal Fistula — Complete Fistula — Treat- 
ment — Palliative treatment — Elastic Ligature — Injection 
of caustics — Incision— Aseptic measures — After treat- 
ment — Complications. 159 

CHAPTER IX. 

ULCERATION 

Fissure — Irritable Ulcers — -Diagnosis — Causes — Treatment — 
Palliative treatment — Incision — After treatment — Grad- 
ual Dilatation — Fissure in children— Divulsion — Rectal 
Ulcer — Classification of Rectal Ulcers — Treatment — 
Ulceration of the Sigmoid — Chief Symptoms — Differen- 
tial Diagnosis — Treatment — Irrigation of the Colon..... 183 

CHAPTER X. 

PROLAPSE OF THE RECTUM 

Falling of the bowel — Classifications — Incomplete — In Chil- 
dren — Causes — Symptoms and Diagnosis — Complete 
Prolapse — Causes — Diagnosis — Treatment for Partial 
Prolapse — Treatment for complete Prolapse — Tuttle's 
Operation 206 

CHAPTER XL 

NON-MALIGNANT GROWTH 

New Growth — Polypi — Neoplasmes — Size of Polypi— Usually 
soft and pliable — Complications — Symptoms and Diag- 
nosis — Classification — Adenoma — Fibroma — Papilloma — 
Teratoma — Lipoma — Cystoma — Enchondroma — Angi- 
noma — Treatment 226 



20 RECTAL DISEASES. 



CHAPTER XII. 

PROCTITIS AND SIGMOIDITIS 

Causes— Puncture of the Bowel — Acute Form— Chronic 

Form — Microscopical Examination — Treatment — The one 

Great Difficulty — Rest— Specific Proctitis— Irrigating the 

Descending Colon — Amebic Dysentery — The Diet 237 

CHAPTER XIII. 

NON-MALIGNANT STRICTURE 

Stricture rare — Occur more often in women than men — 
Causes— Spasmodic Stricture— Pressure from without — 
Tubercular Stricture — Traumatic Stricture — Venereal 
Stricture — Symptoms and Diagnosis — Malignant Stric- 
ture — Treatment — Electrolysis— Instruments— IMethod of 
Procedure 247 

CHAPTER XIV. 

WOUNDS AND OTHER INJURIES 

Common Wounds and Injuries — Causes — Fecal Impaction — 
Accidents — Danger of Injury — Treatment — Foreign 
bodies 265 

CHAPTER XV. 

PRURITUS ANI OR ITCHING OF THE ANAL REGION 

Most intractable disease — Terminal Nerve Filaments — The 
only relief — Removing the Cause — Pruritis — Dr. Bull's 
statement — Intense Itching — Chronic Conditions — De- 
layed treatment — A prevailing cause — Unnatural Dis- 
charge of Moisture — The necessit}- of great care in 
Examinations — Causes of the Irritation — The Author's 
Conclusion — A small shallow Ulcer — Wallis' Conclusion — 
The Examination — The Discharge from small Ulcers — 
Symptoms — Treatment _.. 271 

CHAPTER XVI. 

CONGENITAL MALFORMATION 

Small per cent of Malformations — Necessitv of examining 
the Child at Birth— Simple Narrowing of the Calibre of 
the Bowel — Diagnosis — Treatment — When the opening is 
closed by Membrane — Treatment — Absence of Anus — 
When the Rectum and Anus are Separated— Hopeless 
Cases — Artificial Anus, 289 



CONTENTS. 2i 



CHAPTER XVII. 



RECTAL CANCER 

Most often seen in Adults between Thirty and Sixty Years of 
Age — Oftener in Males than Females — Symptoms — 
Diagnosis — Treatment — Diet — Four Considerations — 
The Importance of early Diagnosis. 298 



CHAPTER XVIII. 

THE REFLEX ACTION OF RECTAL DISEASES 

The Great Nerve Supply in the Rectal Region — Constant 

Irritation — ^"Four Essential Causes of Reflex Action — 

Clinical Cases — General Reflex — Diagnosis — Treatment. 

• 314 

CHAPTER XIX. 

RECTAL EXAMINATION FOR LIFE INSURANCE 

Importance of Physical Examination — Mayo's State- 
ment of Rectal Cancer — Clinical Cancer Cases — Ulcera- 
tion — Symptoms — Cases cited 322 

CHAPTER XX. 

COLOSTOMY: TECHNIQUE OF OPERATION AND 
RESULTS 

Changing the course of Fecal Current — Two General Indi- 
cations — To Divert Temporarily — Permanent Artificial 
Anus — The Operation— The After Treatment — 332 

CHAPTER XXI 

LOCAL ANESTHESIA 

Methods of rendering Tissues Nonsensitive — Chloried 
Spray — Cocaine — Sterile Water Injection — Strength of 
Solutions Used — Electricitv — Many Reasons for Oper- 
ating under local Anesthesia. 341 



LIST OF ILLUSTRATIONS. 



Fig. 


I 


Fig. 


2 


Fig. 


3 


Fig. 


4 


Fig. 


5 


Fig. 


6 


Fig. 


7 



Page 

Electric head light 30 

A good speculum for general use 40 

Sigmoid speculum — 41 

Law's Pneumatic Proctoscope 44 

Plaster cast of rectum 54 

The anal canal 58 

Showing venous lakelets at the termination of 
hemorrhoidal veins which give origin to ven- 
ous internal hemorrhoids 62 

Fig. 8 Showing the nerve supply of the perineal and 

ischio-rectal region 64 

Fig. 10 Electric rectal irrigator 78 

Fig. II ProlaxDsed internal hemorrhoids 98 

Fig. 12 A typical thrombotic hemorrhoid 100 

Fig. 13 Tuttle's rectal speculum 102 

Fig. 14 Copper electrode no 

Fig. 15 Proctoscope or Sphincterscope -II3 

Fig. 16 Slide speculum for injecting piles, treating 

ulcers, etc 121 

Fig. 17 O'Neill's rectal speculum. 124 

Fig. 18 Method of operating with Dr. Mason's contin- 
uous suture clamp 127 

Fig. ig Showing method of operating with the author's 

notched clamp 130 

23 



24 ILLUSTRATIONS 

Page 
Fig. 20 Appearance of parts after continuous suture or 

notched clamp operation on hemorrhoids. - 130 

Fig. 21 T forceps, to be used in grasping hemorrhoidal 

tumors - - 133 

Fig. 22 Galvano cautery ---- 136 

Fig. 23 Sims' rectal speculum as modified by Van 

Buren 137 

Fig. 24 Clamp for cautery operation on hemorrhoids 138 

Fig. 25 Gant's clamp for cautery operation on hem- 
orrhoids - - 140 

Fig 26 Diagramatic representation of an ischio-rectal 

abscess 147 

Submucus Abscess 149 

Diagramatic representation of a pelvic-rectal 
abscess 151 

A pelvi-rectal abscess -154 

Showing T shaped opening in rectal abscess 156 

Blind external fistula 162 

Blind internal fistula 164 

A complete fistula 166 

Fistula 168 

Diagramatic representation of a submucous 

blind fistula resulting from a fissure 173 

Grooved director for operating on fistula 178 

Horseshoe fistula. Lines of incisic-n in oper- 
ating .179 

Complete fistula 180 

Typical irritable ulcer or fissure... 185 

Dilators for gradual dilation of sphincter... ..191 

Cylindrical speculum for examining the higher 

parts of the rectum.. 192 

A good sponge and cotton holder for rectal 

work 194 

Pile pipe for applying ointment to ulcers 196 



Fig. 


27 


Fig. 


28 


Fig. 


29 


Fig. 


30 


Fig. 


31 


Fig. 


32 


Fig. 


33 


Fig. 


. 34 


Fig. 


35 


Fig. 


36 


Fig. 


37 


Fig. 


38 


Fig. 


39 


Fig. 


40 


Fig. 


41 


Fig. 


42 


Fig. 


43 



Fig. 


44 


Fig. 


45 


Fig. 


46 


Fig. 


47 



Illustrations , 25 

Page 

Double current irrigating tube 204 

Complete prolapse of the rectum .....211 

Incomplete prolapse of the rectum 214 

Complete prolapse originating above the internal 
sphincter 218 

Fig. 48 Complete prolapse which begins high in the rec- 
tum or sigmoid and does not appear outside 219 

Fig. 49 Showing the first step in operation of suspend- 
ing prolapsed rectum to sacrum^ 220 

Fig. 50 The prolapsed bowel is now brought out 
through the incision previously made between 
the coccyx and anus and silkworm ligatures in- 
troduced 221 

Fig. 51 With a long Peasley's needle the ligatures are 
carried up through the incision and out on 
each side of the sacrum, each to correspond, 
as nearly as possible to its position in the 
bowel wall , 222 

Fig. 52 All are now tied over a gauze pad drawing the 
bowel up tightly against the anterior wall of 
thesacum. The incision is closed and the 
kangaroo tendon inserted 223 

Fig. 53 Vertical section of simple adenoid (Kelsey) 231 

Fig. 54 Multiple adenoma of rectum (Tuttle) ..232 

Fig. 55 Syphilitic condylomata (Kelsey) 234 

Fig. 56 Snare for polypus and other small growths 235 

Fig. 57 Annular stricture 250 

Fig. 58 Wales rectal bougie 257 

Fig. 59 Tubular stricture 259 

Fig. 60 Showing rectum ending in a blind pouch 

(Kelsey) 292 

Fig. 61 Rectum ending in a blind pouch; anus normal 

(Kelsey) 293 



^6 , ILLUSTRATIONS 

Page 

Fig. 62 Showing rectum ending in the bladder(Kelsey)..249 

Fig. 63 Rectum ending in Glans Penis (Kelsey) 296 

Fig. 64 Inguinal colostomy (Bodine) 335 

Fig. 65 Enterotomy after colostomy (Bodine) 337 

Fig. 66 Showing how the bowel passes between the in- 
ternal and external oblique muscles for about 
an inch before emerging through the skin... 339 



CHAPTER I. 

GENERAL CONSIDERATIONS AND DIAGNOSIS 

Rectal Diseases Very Common — Great sufferers — General 
belief in obscurity — Per cent of Cases the Average Physi- 
cian may Obtain — Equipment — Examination of the Pa- 
tient—Methods of Diagnosis — Symptoms — Protrusion at 
Stool— Pain — Hemorrhage — Discharge — Diarrhoea — Con- 
stitutional Symptoms — Physical Examination — Position — 
Instrumental Examination — Importance of advance in- 
formation — Card used for Record. 

I believe any medical man in general practice 
will agree with me that there is no class of diseases 
that he is called upon to treat in which he obtains as 
unsatisfactory results as in those designated "Rec- 
tal." All will admit that they are exceedingly com- 
mon, and that those afflicted are great sufferers, 
many being entirely unable to perform labor of any 
kind ; these people are not only willing but anxious 
to be cured, and most of them will gladly pay for 
permanent relief. Why, then, does not the physi- 
cian cure them, and thus not only largely increase 

27- 



2B RECTAL DISEASES. 

his earnings, but receive "the grateful appreciation 
of his patrons? 

The reason in most cases is, that the general 
practitioner thinks there is something mysterious 
and obscure about these troubles, making them hard 
to understand, and harder still to treat. I admit 
LJiat many of them are difficult to diagnose, and 
that the treatment is often very perplexing, even 
to those who limit their practice to this kind of 
work, but after many years' experience, I am con- 
fident that fully, fifty per cent of these cases can be 
properly diagnosed and treated by the average phy- 
sician, provided he will take the trouble to go about 
it in the right way. 

Many seem to think that a large number of spe- 
cial appliances and costly instruments are needed, 
and that no one but a specialist is capable of using 
these after they are purchased. In many instances 
this is true, but for most of the cases seen by the 
general practitioner, only the ordinary instruments 
usually at his command are needed. 

A wooden table, such as any carpenter can make, ' 
will do in place of an expensive operating chair or 
table. A cheap irrigator can easily be made by re- 
moving the bottom from a large gallon bottle and 



GENERAL CONSIDERATIONS. 29 

hanging it in\erted in a network of string or small 
chain with the cork securely wired in and a glass 
tube inserted through it, to which four or five feet 
of rubber tubing is attached. 

Some sort of closet should be arranged so that 
enemata may be given. There are many cheap 
forms of tliese on the market, or one can be made 
at small expense. This can be shoved under some 
piece of office furniture, or surrounded by a neat 
curtain so that it will be hidden from view when 
not in use. It is not often that it will be needed, but 
it is indispensable in certain cases. The use of this 
piece of furniture brings up an objection often made 
by physicians against treating these cases, that ''it 
is dirty work." I admit that there are some unpleas- 
ant features about it, as there are about any work 
that one may adopt, but I am sure that the treat- 
ment of rectal diseases is not as unpleasant as that 
of genito-urinary or obstetrical work. 

People who consult their doctors about these 
troubles will usually clean themselves pretty thor- 
oughly before coming, even though not ordinarily 
neat, and if the doctor can, as is usually the case, 
make an appointment with them in advance, he 
can tell them to wash out the bowels well with large 



30 RECTAL DISEASES. 

quantities of hot water, and also to use plenty of 
water on the outside. This need not offend even 
the n:ost sensitive, as it can be explained that it is 
necessary to "relax the parts." If this is well done, 
this portion of the anatomy is as clean as any other 
part of the body, and should it be necessary to give 
an enema in the office, nothing comes from the pa- 
tient except the water introduced. 

A good light is necessary, and daylight is the 
best, although this may be aided by artificial means. 
The use of the little electrical lamps that can be car- 
ried around is often a great help, but is not an ab- 
solute necessity. 



Pig. 1. Electric head light. 

Other instruments needed will readily be sug- 
gested, such as T-forceps, artery forceps, probes, 
directors, scissors, knives, hypodermics, etc. 

As to the best way to make an examination, I 
l3elieve it is always wise to let the patient tell his or 
her own story uninterruptedly. They usually think 



GENERAL CONSIDERATIONS. 31 

they ha^•e piles, and often tell much that is unnec- 
essary, but this senes to wear off the embarrass- 
ment, and a few well-directed questions in conclu- 
sion will clear up the diagnosis as far as it can be 
done in this way. It seems hardly necessary to say 
that no case, however trivial it may seem, should be 
treated without a careful examination. Some most 
amusing and serious blunders have come under my 
notice from neglecting this. 

Lady patients should, if possible, be accompanied 
by their husbands, if married, otherwise by some 
female friend who can assist them in arranging their 
clothing, getting on the table, etc. After this has 
been done, and the patient is lying on her left side 
covered by a sheet, the doctor can make his exam- 
ination without embarrassment to either party. He 
may be able to arrive at a proper diagnosis at a 
glance, or only after considerable trouble. 

It is well to state in this place what can readily 
be seen and felt with the unaided eye and finger. 
There can easily be seen external hemorrhoids, the 
external opening of fistulae, the thickened or parch- 
ment-like or eczematous skin of pruritus. The moist 
appearance indicating a catarrhal condition of the 
bowel farther up, fissures, partly prolapsed internal 



32 RECTAL DISEASES. 

hemorrhoids, venereal diseases, abscess, and after 
a Httle experience, the bulging or unusually prom- 
inent appearance of the parts due to internal hem- 
orrhoids may be recognized. 

There may be felt upon the outside the old 
tracks of fistulae, and by gently pulling the anal 
opening apart with the thumb and finger, fissures 
and irritable ulcers are recognized that are too high 
to come into view without doing this. Occasionally 
the lower part of polypoid growths, or pinworms, 
may be seen. By introducing the oiled finger into 
the bowel there may be felt, first the condition of 
the external sphincter muscle. It will be found to 
vary greatly in different persons. 

In the aged, infirm and debilitated it will in 
most cases be found weak and relaxed, as it is also 
in many persons who have been troubled for a long 
time with large internal hemorrhoids, due to their 
constant protrusion and return, which gradually 
weakens the muscle and causes it to lose to a large 
extent its strength and firmness. 

In the young and vigorous the muscle will be 
found to be firm and resisting, contracting tightly 
on the intruding finger. Sudden force should not 
be used, but gentleness will overcome the resistance. 



GENERAL CONSIDERATIONS. 33 

Pain is usually not complained of in the healthy 
muscle, but if a fissure or irritable ulcer be present 
it will be very severe. 

Farther on may be felt the internal opening of 
fistulae, the depressed rough edge of ulcers, polypi, 
and strictures if not too high, hemorrhoids if well 
developed, although it requires considerable experi- 
ence to distinguish these with the finger, and in 
most cases it cannot be done even by the most ex- 
pert examiner. 

By pressing the finger as far as possible all of 
that portion of the bowel likely to be diseased may 
be felt, and experience will soon teach one to dis- 
tinguish the prostate, neck of the bladder, coccyx, 
uterus, etc. Some experience is required to make 
out all of these, but by frequent examinations one 
soon becomes quite expert. 

In examining women the finger may be intro- 
duced into the x^agina and the whole anterior wall 
of the bowel turned out. In this way internal hem- 
orrhoids, and any other abnormal conditions, in 
most cases, may be readily recognized. 

Another point that should not be overlooked is 
that there may be a complication of diseases. It 
would certainly be very unwise to treat a patient 



34 RECTAL DISEASES. 

for external piles and overlook a stricture. It is not 
uncommon to haAX patients come for treatment for 
some disease that is wholly dependent upon some 
other trouble that to them is unimportant, such as a 
pruritus ani due to a vaginal discharge, or a pro- 
lapse caused by internal piles which force the mu- 
cous membrane down but do not themselves pro- 
trude. 

I have known a patient to be treated in a hospital 
for three weeks for this disease, while the hemorr- 
hoids which were producing it were undiscovered. 

MKTHODS OP^ DIAGNOSIS. 

While much may be learned from the description 
of symptoms as given by the patient, it is only pre- 
liminary to the examination that is to follow. It is 
far too often the case that the family physician 
makes no effort to learn the exact condition other 
than as given by the patient and as a result the 
treatment is carried out along wrong lines. It is 
not uncommon for patients to go to specialists for 
treatment thinking they have hemorrhoids, when 
they are really suffering from an advanced stage of 
cancer, this too, after having received much treat- 
ment from their home doctor. 

Taking up the subjective symptoms first, those 
most often complained of will be discussed. 



GENERAL CONSIDERATIONS. 35 

Protrusion at Stool. This causes the patient to 
seek the advice of a physician more often than any- 
other one thing-. It may be caused by hemorrhoids, 
prolapse, polypoid growth or other tumor. As the 
diagnosis of each of these conditions is to be found 
in the proper place, it is only referred to here to 
show the futility of trying- to make a correct diag-- 
nosis without examinaton. 

Pain. This will often sug-gest pretty accurately 
the nature of the disease. If of recent date it is 
nrobably of an inflammatory nature as an abscess. 
If of lonsf standinsf, it may be carcinoma, a tumor 
higfh in the bowel, a syphilitic deposit, or a chronic 
ulcer. The character of the pain may be important ; 
if of a throbbins: character it shows inflammation 
and the probable formation of pus or possibly the 
stran,eulation of internal piles ; if of a prickinsf or 
stabbing- nature it mig-ht indicate some foreign bodv. 
The time at which it occurs may indicate the cause : 
if it follows a bowel movement and lasts from two 
to four hours and is of a sharp lancinating charac- 
ter it is almost surely due to a fissure. 

Hemorrhage. When blood is passed frorp the 



36 RECTAL DISEASES. 

bowel it nearly always comes from capillary piles 
or from venous tumors that are constricted by the 
sphincter muscle so that the blood is forced out of 
the vein wall. In either case the blood is lost at 
stool. If the amount is small and is noticed imme- 
diately following a bowel movement, and is accom- 
panied with pain of a lancinating, aching character 
it probably comes from a fissure. If it comes on 
independently of the bowel movements it may be 
due to carcinoma or ulcer or it may come from the 
bowel above the rectum. If the attack comes on 
suddenly and has not been noticed before it may be 
due to some foreign body that has lacerated the 
bowels. 

Discharge of Mucus, Pus, etc. Mucus may be 
due to internal piles, catarrhal proctitis, or anything 
that causes an irritation, as polypoid growths, hard 
dry fecal matter, etc. Pus is from an internal in- 
complete fistula or abscess, and pus mixed with 
blood is from an ulceration, a carcinoma, tumors or 
stricture. The symptoms accompanying the dis- 
charge, as pain and the length of time that it has ex- 
isted, will assist in the diagnosis. 

Diarrhoea. A diarrhoea due to rectal disease is 
generally caused by an acute proctitis and is accom- 



GENEI^AL CONSIDERATIONS. 37 

panied by great pain, tenesmus, and symptoms of 
heat, both local and general. If the diarrhoea al- 
ternates with constipation it may indicate a stric- 
ture. If there is constipation so that the fecal mat- 
ter becomes dry and hard it may so irritate the bowel 
wall that an explosive diarrhoea is the result. After 
this has subsided the conditions that produce- it 
gradually return and it occurs again. 

Constitutional Symptoms. Many rectal diseases 
have a striking effect on the general health and the 
constitutional symptoms are as marked as the local 
ones. Among these are the cancerous cachexia, 
nervousness, anemia and loss of weight. Any one 
or all of these may be present. 

Cachexia. This will at once suggest cancer and, 
if combined with loss of weight extending over a 
period of several months, is cjuite a sure indication 
of this disease. 

Nervousness. Rectal diseases in general are sub- 
ject to many reflex nervous syrnptoms caused es- 
pecially by hemorrhoids, fissures and those that in- 
volve numerous nerve filaments. For further in- 
formation the reader is referred to the chapter on 
the reflex action of rectal diseases. 

PHYSICAL Examinations. 



38 RECTfAL DISEASES. 

Preparation of the Patient. In nearly all cases 
it is better to have the patient thoroughly wash out 
the bowel before coming to the office, but in some 
diseases it is important to make the examination 
first in order to ascertain whether or not the rectum 
contains fecal matter, blood, pus, etc. The internal 
opening of an incomplete fistula might not be found 
if all the pus is washed out just before the exam- 
ination. 

After having made the examination an enema 
should be given and the patient requested to retire 
to the toilet room and strain as hard as possible to 
bring out any protrusion that may be present. They 
should be cautioned not to push back anything that 
may be out before getting on the operating table. 

Position of Patient. For all general purposes 
the left lateral position is the best. It is the most 
comfortable for the patient and fills all requirements 
on the part of the doctor. In persons who are very 
fleshy the lithotomy position is much to be preferred 
as the buttocks do not obstruct the view as they do 
when the patient is lying on his side. When the 
lithotomy position is used it should be an exaggerat- 
ed form with the head lower than the body and the 
legs and thighs well flexed. When it is necessary 



GENERAL CONSIDERATIONS. 39 

to introduce the sigmoidoscope this position, will 
prove the most satisfactory and much more comfort- 
able to the patient. 

This position is also very desirable when it is 
necessary to examine other organs, as the vagina, 
bladder, uterus, or the contents of the abdomen. 

I ha\ e seldom found it necessary to ask a pa- 
tient to assume the knee-chest posture. This posi- 
tion is very uncomfortable and embarassing, es- 
pecially to females. Still it has advantages not pos- 
sessed by any of the others, one of which is, that 
owing to tlie flexure of the lumbar portion of the 
spine tlie pelvis is tilted backward thus exposing the 
anal region niore fully than in any other way. It 
also has the advantage of having all of the abdom- 
inal organs fall away from the pelvis by the force 
of gravity, thus straightening the rectum somewhat. 

In some cases where there is a protrusion that 
recedes easily it is important that it be examined 
wdiile the patient is in the squatting position, other- 
wise it will slip back Ijefore he can get on the table 
and a correct diagnosis will be impossible. 

Instriniieiital Bx animation. As a rule but very 
little information can be obtained by an examina- 
tion with the speculum. They simply push the parts 



40 RECTAL DISEASES. 

out of sight behind the broad steel blades and the 
true condition is not seen; or if an instrument is 
used with wire blades the tissue falls between the 
wires at the verge of the anus so that the parts above 
are not seen at all. At best but two or three inches 
are exposed to view and all that can be seen may 
easily be recognized by the educated finger without 
the speculum. 

When to this is added the fact that this instru- 




Pig. 2. A good speculum for general use. 

ment is exceedingly painful it is seen that its use is 
very limited and is seldom called for except when 
general anaesthesia is induced. Still a number of 
these specula should be kept on hand and in cases 
where the sphincter is not too tight and no inflam- 



GENERAL CONSIDERATIONS. 41 

matory condition exists they may be used with con- 
siderable satisfaction. The small conical slide spec- 
ulum does not offer the same objection that the oth- 
ers do and for treating hemorrhoids by injection, 
making applications to ulcers, fissures, etc.. it is 
most excellent. 

In 1895 Howard Kelley described a set of long 
straight tubes which could be introduced into the 
upper part of the rectum, thus showing plainly prac- 
tically all of the organ up to the sigmoid. Since 
that time Law, Tuttle, Pennington and others have 




Fig. 3. Sigmoid Speculum, with long, smooth blades. 
Easy to introduce and not very painful. 

improved upon the method until now they are very 
complete. 

As now arranged, a glass cap is screwed over 



±2 RECTAL DISEASES. 

tlie outer end and a rubber bulb attached by means 
of which air n:ay be forced into the bowel, thus bal- 
looning it so that all folds in the mucous membrane 
are effaced and the entire surface brought into per- 
fect A-iev.-. Anaesthesia is not reqtiired in using these 
tubes ai:d if the knee-chest or lithotomy position is 
asstimed but little if any pain will be experienced. 

After the instrument has passed the internal 
sphincter muscle tlie obturator should be removed 
and the air will at once rush in and balloon the low- 
er part of the rectal potich but the upper portion 
and the sigm.oid will not dilate except by forcing 
the air in. Before the instrument is removed the 
cap should be tak'en off and pressure made on the 
abdomen to get all the air possible out of the colon, 
otherwise the patient may suffer severely from colic. 
One of tliese ttibes should be made cj^uite short, not 
to exceed two incl:es. for examining the lower part 
of the bowel. 

V\diile any ordinary table or operating chair 
will do to make examinations on, I have had one 
made to order that, it seems to me. is as near per- 
fect as it is possible to get it. This is made of steel 
and a hea^y coating of enamel baked on. There are 
no cracks, hidden corners or places not easily 



GENERAL CONSIDERATIONS. 43 

reached, for dust and dirt to gather. It is provided 
with a drain which runs all water or bloody dis- 
charges into a vessel hung on a hook on the under 
side of the top where it is entirely out of sight. 

There is a rubber covered sliding shelf which 
is used for a step, making it very easy to get on or 
off the table. This shelf is very useful also in mak- 
ing examinations as a cushion may be placed on it 
and the patient told to lean over with his knees on 
the cushion and his chest on the top of the table, giv- 
ing a partial knee-chest position which is one of 
the best there is in many forms of rectal exam- 
inations. 

In examining female patients it is important that 
all the pelvic organs be carefully looked after. Many 
times the uterus, ovaries or tubes are more at fault 
than the rectum and the examiner who is not com- 
petent to diagnose and treat all abnormal conditions 
found here is not as a rule competent to treat any 
of them. 

Exploratory Laparotomy. If there is strong rea- 
son to suspect disease of the bowel too high to diag- 
nose from below, the abdomen should be opened 
and the true condition ascertained. Arrangement 
may be made to operate at the same time if the con- 



44 



RECTAI. DISEASES. 



sent of the patient and friends is obtained and the 
conditions justify it; or this may be postponed until 
some future time as thought best. With present 
methods of asepsis there is but Httle danger in an 



m 



y|imtt«iiiM||^|||y 




Fig. 4. Law's Pneumatic Proctoscope. E. 1, 2, 3, obtura- 
tors; A, B, C, tubes, D, handle; F, cap with glass win- 
dow; G, inflating bulb; H, battery connection; J, K, 
electric light and insulating rods. 

exploratory incision. 

I give below a copy of advance information that 

I have had printed in the form of little slips and 



GENERAL CONSIDERATIONS. 45 

when I know that a patient is coming to see me for 
the first time I give or send one to him and in this 
way find that he is ahiiost invariably well prepared 
for an examination. 

I also give the form of some cards that I keep 
on hand to record my cases. These cards are kept 
arranged in alphabetical order and are a very great 
convenience for future reference. They can be 
filled while the history is being taken and are but 
little bother. It is a great convenience in case some- 
one whom you treated a year or more ago writes 
or calls on you, to be able to look the matter up at 
once and not have to depend on memory. I carry a 
few of these in my pocket and should a case be seen 
in the hospital or at the patient's home the record 
can be taken. In case there is not enough room the 
back may be used. The letters ''M. F." stand for 
male or female, and "M. S. W." for married, single 
or widow, (widower). Simply cross out the ones 
not wanted. 

ADVANCE INFORMATION. 

// you arc coming to rnc for treatment of rcctal 
disease, please observe the follozving advice ; 



46 RECTAL DISEASES. 

Tzvo days before you expect to he in my office 
for cxaniinaton take a good physic. It is not so 
very important zvhat it is so it acts freely, but 
two or three of the compound cathartic pills 
zi'hich any druggist zvill furnish you zvill be 
the best. This should be follozved the next day 
zi'ith a fezv small doses of Rochelle salts, say a 
heaping teaspoonful in a cup of zvater, pref- 
erably hot. The evening before coming, take 
one or more injections of hot zvater, to zvhich 
has been added a little soap. If you are not to 
get to the office until afternoon it is zvell to 
repeat the injection in the morning before 
coming. 

A little trouble on your part zvill save you 
considerable annoyance and possibly a day or 
more of time, besides being much more pleasant 
for both of us. 

f Mease keep this slip for future reference, if you are 
not coming now. 

R. D. MASON, M. D., 

Brand eis Block, corner i6th and Douglas Sts,, 
Omaha, Neb, 



GENERAL CONSIDERATIONS. 



47 



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CHAPTER II. 

ANATOMY 

The essential points — Bones of the Pelvis — The Pelvis — 
The Muscles — Sphincter Ani — Internal Sphincter — 
Levator Ani' — Coccygeus — Perinei — The Rectum — The 
Arteries — The Veins — The Nerves-^The Perineum and 
Ischio — Rectal Region — The Female Perineum. 

In order to have a correct knowledge of rectal 
diseases and their treatment it is essential that a 
clear understanding be had of the normal anatomy 
of the parts. It is not necessary to go into the sub- 
ject ^ ery carefully and describe each part in de- 
tail as it would take up too much space, but the es- 
sential points will be gone over with sufficient clear- 
ness to give a good working knowledge of the parts. 

BONKS. 

The bones of the pelvis consist of the two ossa- 
innominata, which bound it on either side and in 
front; the sacrum and coccyx w^hich complete it 

48 



ANATOMY. 49 

beliind. These form a broad, cup-shaped cavity 
Vvhich is said to resemble a basin. It is the most 
strongly constructed of the bony frames of the body 
and is interposed between the spine, which it sup- 
ports, and the lower extremities upon which it rests. 
The pch is is di\'ided into two cavities by the illio- 
pectineal line, that above this line being called the 
false pelvis and that below the true pelvis. Most of 
tl.e organs under consideration are in the true pelvis. 

MUSCluE^S. 

Beginning from the outside the first muscle is 
the sfhincter Ani Ext emus or external sphincter. 
This is a true spliincter and surrounds the terminal 
portion of the large intestine. It arises from the 
dorsal aspect of the tip of the coccyx and also the 
ano-cocygeal ligament; and after dividing to sur- 
round the anus, is inserted into the central point of 
the perineum. This muscle consists of two strata, 
a superficial and deep. The former is mostly sub- 
cutaneous and the fibres are inserted into the skin 
while the deep fibres are inserted into the outer 
layer of the rectal wall. This is a purely voluntary 
muscle, and, being under the control of the will, is 
of the utmost importance. It relaxes readily during 



50 RECTAL DISEASES. 

the passage of feces and contracts to its former po- 
sition after the bowel has been emptied. While it 
is a voluntary muscle it is not entirely under the 
control of tl:e will, but is largely so. 

Because of its exposed position it is very sub- 
ject to injury and often becomes hypertrophied and 
miore or less firmly contracted so that it offers con- 
siderable resistance to the passage of feces, and di- 
vulsion or stretching is necessary to overcome the 
resulting constipation. 

The nerve supply is from the inferior hemorr- 
hoidal branch of the pudic and the perineal branch 
of the fourth sacral. 

Internal Sphincter. This muscle is simply an ag- 
gregation of the lowermost circular muscular fibres 
of the rectum. It is an involuntary muscle and keeps 
the canal closed when the will power is not under 
control, as in sleep, anaesthesia, etc. The division of 
this muscle will occasionally result in partial incon- 
tinence, although if properly done this is not likely 
to occur. 

There is said to be a third sphincter above this 
but it is of so little importance that it will not be 
further considered. 

Levator Ani. The description of this muscle as 



ANATOMY. 51 

given by Grey is as follows : "The Levator Ani is a 
broad, thin muscle, situated on each side of the 
pelvis. It is attaclied to the inner surface of the 
sides of the true pelvis, and, descending, unites with 
its fellow of the opposite side to form the floor of 
the pelvis cavity. It supports the viscera in this 
cavity, and surrounds the various structures which 
pass through it. * It arises, in front, from the pos- 
terior surface of the body and the ramus of the 
pubes, on the outer side of the symphysis; posterior- 
ly, from the inner surface of the spine of the ischium ; 
and between these two points, from the angle of the 
division between the obturator and recto-vesicle lay- 
ers of the pelvic fascia at their under part ; the fibres 
pass dov.nv/ard to the middle line of the floor of the 
pelvis, and are inserted, the most posterior fibres 
into the sides of the apex of the coccyx; those placed 
anteriorly unite with the muscle of the opposite side, 
in a median fibrous raphe, which extends between 
the coccyx and the margin of the larger portion of 
the muscle, are inserted into the sides of the rectum, 
blending with the fibres of the sphincter muscle; 
lastly the anterior fibres, the longest descend upon 
the side of the prostate gland to unite beneath it 
with the muscle of the opposite side, blending with 



52 RECTAL DISEASES. 

the fibres of the external sphincter and transversus 
perinaei muscles at the tendinous centre of the peri- 
neum." This muscle forms the floor of the pelvis, 
dividing- the contents of the true, from that of the 
false, peh'is. Its function is to hold the contents of 
the upper peb.'is and abdomen away from the anal 
outlet. It also acts by compression as an aid in 
forcing the contents of the bowel out in a defecation 
and at the same time by the contraction of its fibres 
the neck of the bladder is compressed and the urethra 
closed. It receives its nerve supply from the perin- 
eal branch of the fourth sacral and the deep branch 
of the perineal division of the pudic. 

Coccygeiis. "This muscle is behind and parallel 
with the preceding. It is a triangular plane of mus- 
cular and tendinous fibres, arising, by its apex, from 
the spine of the ischium and the lesser sacro-sciatic 
ligaments, and inserted, by its base, into the margins 
of the coccyx and into the sides of the lower piece 
of the sacrum. This muscle is continuous with the 
posterior border of the Levator Ani, and closes the 
back part of the outlet of the pelvis. Its action is 
to raise and support the coccyx after it has been 
pushed back during the defecation or parturition.'' 
The nerve supply same as the Levator Ani, 



ANATOMY. 53 

J'ransz ersus Fcrhiei. "This is a narrow mus- 
cular slip, which passes more or less transversely 
across the back part of the perineal space. It arises 
by a small tendon from the inner and fore side of 
tlie tuberosity of the ischium, and, passing obliquely 
forward and inward is inserted into the central ten- 
dinous puint of the perineum, joining in this situa- 
tion with the muscle of the opposite side, the sphinc- 
ter ani behind, and the accelerator urinae in front." 
In the female tins muscle is inserted into the side 
of the sphincter \agina, and the Levator Ani 
into the sides of the vagina and rectum. 

, THE RECTUM. 

This constitutes the lower eight or nine inches 
of the large intestine and extends from the left sacro- 
illiac-synchondrosis, at which point it is a continua- 
tion of the sigmoid flexure, to the anus. This organ 
is not straight but has three distinct curves as fol- 
lows : From its starting point at the left of the spinal 
column it extends downward and Ijackward into the 
hollow of the sacrum and at the same time it curves 
to the right so that it lies in the center of the body 
instead of at the left ; after reaching the hollow of 
the sacrum it curves forward until it reaches the tip 



54 



RECTAL DISEASES. 



of the coccyx when it again turns backward until it 
reaches the outside. It somewhat resembles the let- 



Fig. 5. Plaster cast of rectum, showing curves, 
ter S and these curves should be borne in mind when 
attempting to pass instruments. For facility of de- 
scription the rectum is divided into three parts as 
follows : The upper portion from the starting point 



ANATOMY. 55 

to the middle of the third piece of the sacrum; the 
second from, this point to the tip of the coccyx ; and 
the third from there to the lower end. 

Upper Portion. This is from four to five inches 
in the adult and is entirely covered by peritoneum 
which forms a meso-rectum which attaches it to 
the back part of the pelvis. As before stated it is 
directed downward, backward, and to the right, and 
ends at the n.iddle of the third piece of the sacrum. 
This portion is very similar to the bowel above and 
some claim should not be classed as part of the 
rectum. 

R.-.ct'.cns. Coils of small intestines, the bladder 
V. liCn distended, the uterus u-lien enlarged, and the 
ovaries and tubes are in front and extending on each 
side. Eehiiid lie the three pieces of the sacrum, the 
pyriforniis nvascle, and die meso-rectum containing 
the hemorrhoidal vessels. On the left are the ureter 
and branches of the interna] iliac artery. 

Middle Portion. This is about two and a half 
inches long and extends from the middle of the third 
piece of the sacrum to the tip of the coccyx. The 
most of this portion is co\'ered by peritoneum in 
front and at the sides but not beiiind; for this rea- 
son the rectum is not attached to tr:e pelvis at this 



56 RECTAL DISEASES. 

point, having no meso-rectum, but is freely movable. 
In front the peritoneum in the male is reflected on to 
the bladder, and in the female on to the vagina form- 
ing Douglas pouch. 

Relations. In front, in the male, the recto- ves- 
ical pouch of the peritoneum, the base of the bladder, 
the seminal vesicles, and the prostate. In the fe- 
male, Douglas pouch and the posterior wall of the 
vagina. Behind there is nothing but the concave 
portion of the sacrum and some loose areolar tissue 
together with a few lymphatic glands. 

Lower Portion. This measures about one and a 
half inches and extends from the tip of the coccyx 
backward to the outside. It is surrounded by both 
the internal and external sphincter muscles which 
reduces it to a narrow closed canal. This is the part 
that is the most exposed to traumatism and wliere 
we may expect to find hemorrhoids, fistulas, fissures, 
etc. , There is no peritoneum around this portion. 

Relations. In front in the male are to be found 
the apex of the prostate, the base of the bladder, the 
triangular ligament, the perineal body, and the ureth- 
ra. In the female the lower part of the posterior 
wall of the vagina and the perineal body. Behind 
are the ano-coccygeal ligament, the posterior fibres 



ANATOMY. 57 

of the levators ani and the origin of the external 
sphincter. On each side are to be found the ischio- 
rectal fossa. 

Structure of the Rectum. There are four coats, 
the serous, muscular, sub-mucous and mucous. 

The Serous Coat. This is the peritoneum and has 
been described in speaking of the curves to which 
the reader is referred. 

Muscular Coat. The muscular fibres are ar- 
ranged in two distinct layers, the outer longitudinal 
and the inner circular. 1 he longitudinal is a con- 
tinuation of that found in the colon and is divided 
into three layers ; the outer is inserted into the pelvic 
fascia, the middle ijlend with those of the levator 
ani, and the internal pass down by a series of fine 
tendons between the internal and external sphincter 
muscles and are inserted into the skin at the anal 
margin. The circular fibres are for the most part 
uniformly distributed but at the lower end they are 
gathered into a thick Ijand constituting the internal 
sphincter, which lias been described. 

Suh-iiiucous Coat. This is the coat in which 
the vessels, nerves and lymphatics are to be found. 
It is a loose mass of areolar tissue inside the mus- 



5^ RECTAL DISEASES. 

cular layer and upon which rests the mucous mem- 
brane. 

The Mucous Membrane. This is very vascular 
and moA^es freely on the sub-mucous tissue. When 
at rest it is thrown into folds which are mostly ef- 
faced when the bowel is distended. Certain of these 
are not effaced during distention, these are called 



'i 

, - _ . . . J 



Fig. 6. The anal canal. A, columns of Morgagni; B, semi- 
lunar valves or crypts of Morgagni; C, dentate border, 
marking upper limits of anus and surmounted by pap- 
illae; D, Hilton's white line. — Tuttle. 



Houston's folds. Immediately above the muco-cu- 
taneous junction are other folds running in a longi- 
tudinal direction and called the ''Columns of Mor- 



ANATOMY. 59 

gagfii." These are no doubt caused by the constrict- 
ing effect of the sphincter muscle. Between these 
columns are to be seen folds of mucous membrane 
called pockets and more correctly known as the 
''Valves of Morgagni.'' These so-called pockets are 
a source of great profit to many irregular practi- 
tioners as they tell their patients of the direful re- 
sults that will ensue if they are not cut out. They 
promise to cure anything from corns to consumption 
by cutting out these pockets. There is some doubt 
as to their exact function, but it is now believed by 
n ost ailhorities that they are to gather and hold 
mucus to lubricate the fecal n.ass in passing out and 
tluis protect the mucous membrane from injury. 
Ball says they are often torn loose at the edges by 
1 ard fecal passages and gradually work down in 
tlie form of a hard mass called a sentinel pile. The 
torn tissue above them results in an irritable ulcer. 

ARTERIES. 

Superior Hemorrhoidal. This artery is a direct 
continuation of the inferior mesenteric and descends 
into the pelvis between the layers of the meso-rec- 
tum, crossing, in its course, the ureter and the left 
common Iliac vessels. Opposite the middle of the 



6o RECTAL DISEASES. 

sacrum, it divides into two parts which descend one 
on each side of the rectum, where they divide into 
several smah branches which are distributed between 
the mucous and muscular coats of that tube, nearly 
as far as its lower end ; anastomosing with each oth- 
er, with the middle hemorrhoidal arteries, branches 
of the internal iliac, and with the inferior hemorr- 
hoidal branches of the internal pudic. 

The student should especially note that the trunk 
of the \ essel descends along the back part of the 
rectum as far as tlie middle of the sacrum before it 
divides, this is about a finger's length or four inches 
from the anus. In operating on this part of the 
bowel tliis should be remembered and great cautiu^. 
be used. 

7 he Middle Henwrrhoidal Artery is a branch of 
the anterior division of the internal iliac. It is dis- 
tributed mainly to the niiddle portion of the rectum 
and its branches anastomose freely with the superior 
hemorrhoidal. It supplies chiefly the muscular L'y- 
er of the bowel. 

Tlic Infci ior Hcinorrhoidal Artery is a branch of 
the internal pudic as it passes above the tuberosity 
of tlie ischium. It crosses the ischio-rectal fossa and 
is distributed to tlie muscles and integument of the 



ANATOMY. 6i 

.'iiial region. This artery or some of its branches 
are often cut in operations for fistula, but as they 
are small tliey seldom require ligating. 

VEINS. 

The veins of the rectum are very numerous and 
are known as th.e sUj)erior, middle and inferior hem- 
orrhoidal to correspon.d with the arteries. These 
are in tlie form of a venous plexus rather than indi- 
vidual veins. 

7 lie Superior Hemorrhoidal vein collects the 
blood from the rectum itself, and not much from 
the surrounding parts, and empties it through the 
mesenteric into the portal system. The middle and 
inferior hemorrhoidal ^ eins collect the blood from 
the external surface of the anus and skin and re- 
turn it into the vena-cava. The dividing line is said 
to be the n:uco-cutaneous junction. For this rea- 
son it is easily seen that internal hemorrhoids are 
always an affection of the superior hemorrhoidal 
veins v^hile the external are always connected with 
the middle or inferior hemorrhoidal. Slightly above 
the muco-cutaneous junction there are many small 
venous pools of blood in the shape of little lakelets, 
each distinct in itself and yet freely anastomosing 



62 RECTAL DISEASES. 

with the others. They are just under the mucous 
mtn-.brarie and extend entirely around the bowel. 
About a finger's length above the anus, venous 
branches enter the bowel wall through holelike aper- 



r 






Fig. 7. Showing venous lakelets at the termination of 
hemorrhoidal veins which give origin to venous in- 
ternal hemorrhoids. 

tures. The ingenious theory has been advanced that 



ANATOMY. 63 

the contraction of these slits, due to constipation, 
straining at stool, etc., l^y impeding the circulation is 
a potent cause of hemorrhoids. As the veins have 
no valves and because of the lake-like arrangement 
below this point, as pre\'iously noted, the theory is a 
very sensible one. 

The Middle Heinorrhoidal is distributed to the 
outer surface of the ^'ectum above the levator ani 
muscle. It receives the blood from the muscular 
coats of the bowel and does not anastomose very 
freel}^ with the other veins. 

The Inferior Hemorrhoidal is arranged around 
the sub-cutaneous tissue of the anus and is the ve- 
nous plexus involved in external hemorrhoids. 

NERVES. 

These are from the spinal and sympathetic sys- 
tems. The latter are from the inferior mesenteric 
and hypogastric plexus and are distributed to the 
muscular coat and mucous membrane including the 
internal sphincter. 

The spinal nerves are from the third and fourth 
sacral and the piidic. The fibres enter the rectum 
between the internal and external sphincter muscles 
and are distributed very freely to the lower end of 



64 



RECTAL DISEASES. 



the bov.el and adjacent skin. Owing to this free 
distribution, operations here are the most painful of 
any in surgery. This is also especially noticeable 
in cases of fissure. The fact that these same nerves 
are distributed freely to the bladder, prostate, ureth- 




X: 




Fig. 8. Showing the nerve supply of the perineal and 
ischo-rectal region. 



ra, etc., accounts for the pain felt in these organs in 
case of rectal disease as it does also for retention of 
urine in operations in this region. 

THE PERINEUM AND ISCHIQ-RECTAI, REGION. 

"This corresponds to the inferior aperture or 
outlet of the pelvis, Its deep botmdaries are, in 



ANATOMY. 65 

front, the pubic arch and super pubic Hgament, be- 
hind, the tip of the coccyx; and on each side, the 
ramus of the pubes and ischium, the tuberosities of 
the ischium, and the great sacro-sciatic hgament. 

The space inchided by these boundaries is somewhat 
lozenge-shaped, and is hmited on the surface of the 

body by the scrotum in front, by the buttocks be- 
hind, and on each side by the inner side of the 
thighs. It measures, from before backward, about 
four inches, and about three in the broadest part 
of its trans\erse diameter, between the ischial tub- 
erosities. A line drawn transversely between the 
anterior part of the tuberosity of the ischium, on 
each side, in front of the anus, sub-divides this space 
into two portions. The anterior portion contains 
the penis and urethra, and is called the perineum. 
The posterior portion contains the termination of 
the rectum, and is called the ischio-rectal region." 

The ischio-rectal Fossa. This is the space be- 
tween the tuberosity of the ischium and the rectum. 
It is a pyramidal shaped space with the apex directed 
upward and the base corresponding to the surface 
of the skin. It is composed of a quantity of fat and 
loose areolar tissue which is very distensible to al- 
low the rectum to expand for the passage of fecal 



66 RECTAL DISEASES. 

matter. There are numerous comiective tissue bands 
that divide the fossa into compartments which ac- 
coriits for the fact that pus is not in one large ab- 
scess but in numerous small ones. The space is 
crossed by numerous blood vessels and nerves, but 

none of them are important. Owing to the fact that 
the connective tissue and fat are continuous from 

side to side behind the rectum, when an abscess oc- 
curs in one fossa it is very likely to burrow between 
the levator ani and the coccygeal attachments of the 
external sphincter until it gets into the fossa on the 
other side, forming, when the internal opening into 
the bowel and the two external openings have oc- 
curred, the so-called l:orse shoe fistula. 

Tlie Skill is thick and closely adherent to the un- 
derlying fascia. Over the external sphincter muscle, 
scattered bundles of involuntary muscular fibres are 
found which radiate from the interior of the anus. 
This is the cornigator-cufis-ani muscle. By its con- 
traction it raises the skin into ridges radiating from 
the margin of the anus. 



CHAPTER III. 

CONSTIPATION 

As a S3'mptom — Constipation due to Specific Canses — What 
is meant b}' constipation — Normal Bowel Movement--- 
"Alimentaiy Constipation" — Lack of residue in the bowel 
not constipation — Intestinal Indigestion — The lack of 
Fluids in Food — Training the Bowels — Physiology of 
Defecation — Other causes of Constipation — Characteris- 
tics of the Stools — Diagnosis — Treatment — Boas' Diet- 
List — Mechanical Treatm^ent — Massage — Vibration — 
Electricity — Rectal Lavage — Exercise — Drugs. 

This condition may be acute or chronic and is 
often spoken of as a symptom of some more serious 
trouble, but many authorities- now believe that it 
may be and often is a distinct entity, due to well de- 
fined and specific causes. 

By constipation is meant "infrequent or incom- 
plete aline evacuations leading to the retention of 
feces." This may mean that the bowels do not move 
with sufficient frequency or it may mean that there 
is not sufficient c^uantity at each movement. 

There is no absolute rule as to the length of time 
that should elapse between evacuations, but in the 
healthy individual one bowel movement daily is gen- 
erally considered normal. This, however, may vary 
greatly and still be within the limits of health. Cer- 

67 



68 RECTAL DISEASES. 

tain persons may ha\ e tv\0 nio\ ements daily, others 
n:av go two or three days and seem to suffer no 
incc)nvenience. • It is not unusual for some people 
1o allo\\.' from one to two v. ee'-rs to pass between 
evacuations, but this is, as a rule, to the serious im- 
pairment of their health. 

The so-called "alimentary constipation," or that 
due to errors of digestion, is so closely allied to otli- 
er conditions that it is difficult to say just wliich 
is the cause and which the effect. 

• It is not at ah uncommon to find patients who 
complain of constipation vTio do r.ot eat enough to 
give bulk to the intestinal contents and as a result 
peristalsis does no good as there is not enough for the 
bowel to grasp and it cannot be properly pushed on. 

This is especially true among that class of pa- 
tients who live on dainties and rich foods that pro- 
duce but little residue and also among children who 
have passed the period of weaning, but who still 
remain on a milk diet. Here nature does not bring 
on a bowel moAcment as often as may be thought 
necessary, because there is but little that should pass 
away. This is not constipation at all. 

On the other hand the reverse condition may 
exist. There are a great mamy people who are ex- 



COXSTIPATION. 69 

cessive eaters and who bolt their food, not only in 
large quantities, but improperly masticated. 

Here the entire intestinal tract is overworked 
and an intestir.al catarrh is established with the 
formation of intestinal gases and the abstraction of 
the liquid portion of the food without its being prop- 
erly mixed- with the intestinal juices and we have 
the clinical picture of intestinal indigestion with its 
accompanying constipation. Many also suffer from 
constipation because of a lack of fluids in the body. 
They do not drink enough water. 

Thic composition of feces should be normally 
about 75 per cent Vv'ater. When this falls to 50 per 
cent or less an action of tlie bowels is nearly im- 
possible. 

Of course, otlier things besides the drinking of 
an insufficient amount oi water may produce dry 
stools, as excessixe perspiration, diabetes, etc. Indi- 
viduals \ary so much in regard to the amount of 
fluids needed that it is difficult to adx'ise them until 
they have been under obser\ation awhile. 

There is another condition which w ill bring about 
chronic constipation and which lies wholly under the 
control of tlie will and this is non-attention to the 
calls of nature. 



^6 RECTAL DISEASES. 

Almost anyone may train their bowels to move 
at just such intervals as they see fit and for this 
reason we find those low in the scale of intelligence 
more likely to suffer from this condition than those 
who, because of superior knowledge and training, 
know that regular evacuation of the bowels is of 
great importance and to neglect it means serious 
impairment of health. 

The lower we go in intellectual capacity the more 
pronounced does this become. It is a well known 
fact that in our homes for feeble minded and asy- 
lums constipation is one of the most important things 
to be guarded against. 

If not looked after it is not uncommon to have 
many cases of fecal impaction to care for. Nature 
is very quick to resent any violation of her laws and 
inflicts severe penalties on those who disregard them. 

It might be wxll to consider briefly the physiol- 
ogy of defecation. Normally the lower end of the 
colon or that portion lying in the true pelvis is the 
true reservoir for fecal matter prior to its evacua- 
tion from the body. At regular intervals about once 
every twenty-four hours the mass passes down into 
the rectal cavity and the pressure made on the nerves 
of sensation conveys to the brain the fact that an 
evacuation of the bowels is ready to' take place. 



CONSTIPATION. 71 

At this point the process is in most instances 
purely vohmtary and under the control of the will 
and may be heeded or disregarded. In case it is 
disregarded the desire soon passes away and as a 
rule is not felt again for another twenty- four hours. 
Whether any or all of the material that was forced 
into the lectal pouch returns to the sigmoid is a dis- 
puted question, but in either case if this occurs often, 
considerable harm results. 

In the first place the nerve centers soon become 
accustomed to the pressure constantly made upon 
them and do not respond as they should; gradually 
the desire is felt less and less until in some instances 
it is almost entirely lost. 

Then again by remaining in the body long after 
it should have been cast off it becomes dry by hav- 
ing its moisture absorbed and soon a chronic proc- 
titis and sigmoiditis result. This chronic catarrhal 
condition with its outflow of mucus soon gets the 
sphincters hypertrophied and in a spastic condition 
and they refuse to dilate except under the influence 
of powerful cathartics. 

This I believe to be one of the great unrecog- 
nized causes of constipation. I might add in pass- 



^2 RECTAL DISEASES. 

ing that this rectal catarrh is a most prohfic cause of 
pruritus ani. 

Constipation may also be produced by purely 
mechanical means and physical conditions or disease 
of other organs or parts only indirectly related to 
the digestive tract such as paralysis, pregnancy, pres- 
sure from tumors, or adhesive bands, binding the 
bowels down, stricture, hypertrophy of the rectal 
valves, hemorrhoids, the accumulation of fecal tu- 
mors, especially in the ceacum, a retro-flexed and 
congested uterus tipped back into the hollow of the 
sacrum, and also from pain due to an irritable ul- 
cer at the muco-cutaneous junction. The constipa- 
tion following paralysis will of course depend on the 
parts affected and may l^e complete or partial. 

If the lower limbs are seriously affected there 

is generally complete loss of power in the sphincter 

muscles and the peristaltic action of the bowels above 

causes the feces to flow away at irregular intervals 

without regard to any desire being felt. On the oth- 
er hand there may be a paralysis of the bowel itself, 

which will stop all or nearly all peristaltic action. 

It is often said that pregnancy causes constipa- 
tion by the pressure which the gravid uterus pro- 
duces on the large intestine. This is true to a lim- 



CONSTIPATION. 73 

ited extent only and occurs mainly in the early 
months while the uterus is low in the pelvis. 

As soon as it gets big enough to produce much 
pressure it begins to rise into the abdominal cavity 
and tip forward, just the exact conditioub that we 
would want to relieve pressure had it been present. 
The cause in my opinion is partly due to the large 
amount of fluids taken from the blood to nourish 
the child and also to the changed life of the moth- 
er, lack. of exercise, worry and general disturbed con- 
dition of the nervous system. 

Tumors in the pelvis may bring about the con- 
dition by partially occluding the bowel and adhesive 
bands following operations may do the same thing. 
Stricture, either malignant or benign, is often a 
cause, and is seldom recognized until it becomes so 
severe as to almost occlude the bowel. 

Strictures of large calibre may exist for years, 
in fact, may be congenital and be the cause of most 
obstinate constipation without being discovered. 

Hypertrophy of the rectal valves is often spoken 
of as a cause, but in my opinion this condition is 
very infrequent. 

Pain will cause constipation by inducing the indi- 
vidual to postpone bowel movements as long as pos- 



74 RECTAL DISEASES. 

sible and thus bring about the same conditions spok- 
en of under catarrhal proctitis. 

Boas speaks of the atonic and spastic form of 
the disease. He says : "The atonic variety is the 
usual form of constipation that depends upon simple 
weakness of the intestine, such as usually develops 
under improper habits of living and eating." Ac- 
cording to Kleiner, the stools are drier and firmer 
than usual, and consist of compressed and dessicated 
lumps or cylinders of large calibre, or of distinct 
particles or scybalae bearnig the impress of the sac- 
culations of the colon.'' This is really the same con- 
dition spoken of under the head of the digestive or 
catarrhal form and is due primarily to errors of di- 
gestion. 

Ke also says : "The spastic form is due, accord- 
ing to Fleiner, to the retention of firm masses of 
feces within segments of spastically contracted in- 
testine, somewhat as in lead colic. It is found chief- 
ly in women with pelvic disorders. The stools have 
the following characteristics : long or short cylinders 
of small calibre, often no thicker than a pencil or 
the little finger, or spherical masses the size of a 
hazel nut. The latter formation is not character- 
istic of spastic constipation, as it is also found in 



CONSTIPATION. 75 

the atonic form ; it is only when it is constantly pres- 
ent that it is significant." This spastic form is due 
to a tonic contraction of both the circular and lon- 
gitudinal muscular fibres of the small intestine pre- 
venting peristalsis; this also, in my opinion, is only 
another one of the many manifestations of gastric 
and intestinal catarrh, although it is probably more 
often due to some obscure nervous trouble and one 
of the conditions termed illius sometimes following 
abdominal operations. 

The diagnosis of constipation is usually con- 
sidered easy ; the fact that one is constipated is gen- 
erally diagnosed by the individual before he consults 
the doctor, but the real cause is often most diffi- 
cult to discover. 

A thorough and most complete examination 
should be made, and this should include a careful 
rectal examination for hemorrhoids, stricture, tu- 
mors, fissure, etc. Also for tumors of the pelvis 
and abdomen, misplacement of the uterus, enlarged 
prostate and fecal tumors, the possible after results 
of any operation that may liave been done in the 
past. If the patient is past middle life and the 
trouble has developed in a rather short period of 
time after having been regular, stricture from ma- 



jG RECTAL DISEAvSES. 

lignant disease should be suspected. If there is ema- 
ciation with frequent attacks of cohc and a saUow 
cachectic looking skin the diagnosis is quite certain. 
It is only necessary to refer tlie reader to the causes 
already enumerated to suggest the character of the 
examination. 

Treatment. This consists in using such methods 
and remedies as v\ ill induce tlie bowels to move at 
regular and somewhat frequent intervals. The way 
this ma}^ be accomplished depends largely on the 
cause. If the patient is suffering from the so-called 
atonic form, due to indigestion and the digestive 
canal has got into a chronic catarrhal condition his 
entire njjde of life should be clianged if possible. 

Boas gives a diet-list which may serve somewhat 
as a guide and can be modified to suit individual 
patients. 

■ Tliis is as follows : 7 a. m., a glass of cold water; 
8 a. m., a liberal lireakfast, v\ith sweetened coffee, 
a good deal of butter, honey and graham bread. 
After tl is tlie patient should go to stool. 

One p. m., n-idday n.eal of meat, a good deal of 
vegetables, salad, stewed fruits, farinaceous food, 
v^■ith wine, water or tea. 

Seven p. m., meat, with a good deal of butter, 



CONSTIPATION. ^^ 

o-raham bread, stev\"ecl fruit, beer, vrater or tea. 

Ten p. 111., ste\\'ed or fresh fruit (apple). To 
persons witli whom it agrees, buttermilk may be 
given. 

It is hardly necessary to remark that the above 
is useful only in uncomplicated cases of atonic con- 
stipation. 

Mcdianical treat incut. In addition to the above 
I Avish to recommend massage, or what is still bet- 
ter and more easily applied by the general practition- 
er, vibration. 

The technique, as carried out by myself, is as 
follows : With a rather slow vibration and heavy 
stroke the A'ibrator is placed over the ceacum and 
slowly moA^ed along the course of the colon. After 
reaching the sigmoid it is lifted off the abdomen 
and the operation repeated. At first the abdominal 
muscles will contract and but little pressure should 
be made, but after a short time they will relax and 
the applicator should be pressed down with consid- 
erable force. In thin persons this will break up 
any fecal masses that may be present, draw the 
blood to the parts and tone up not only the abdom- 
inal wall, but the muscular coats of the bowel. 

Great care should be taken to not use this method 



7^ 



RECTAL DISEASES. 



in inflammatory ccnditicns or where there is the 
least suspicion of an abscess. Considerable harm 
might result ; however, after all inflammatory con- 
ditions have passed away this method may break ad- 
hesions and thus free the bowel so that it may more 
naturally perform its functions. It should of course 
not be used in any form of intestinal destruction. 
This treatm.ent should be kept up daily for several 
weeks and then at less frequent intervals for as 
much longer. 




Fig. 10. Electric Rectal Irrigator. 

Electricity is useful in many cases combined with 
the above. 

Rectal lavage is the very best treatment that can 



CONSTIPATION. 79 

be used in paralytic conditions of the colon. This 
is done in the following way: An insulated rectal 
tube with many perforations at the end and pro- 
vided with both an inflow and outflow connection 
for water (see Fig. 10). The inflow tube is at- 
tached to the water bag, being two or three feet 
above the patient. The outflow tube should be just 
long enough to allow the water to run into a vessel 
on the floor. One pole of the faradic current is now 
connected to the rectal tube and the other placed on 
the abdomen. The w^ater is now turned on and the 
colon filled as full as the patient can conveniently 
bear it. when the outflow tube is opened and a weak 
electric current turned on. The abdominal electrode 
is now moved over the colon, following its course 
from the ceacum to the sigmoid. 

Care should be used that the water does not 
flow out any faster than it flows in or the colon will 
be empty before sufficient treatment is given. If 
there is not sufficient water to last long enough. 
shut off the outflow so v/hat is in the colon may be 
retained. The sensation of the patient is the best 
guide as to the strength of the current. Where the 
trouble is more general than local I think the faradic 



8o RECTAL DISEASES. . 

current applied along the spine with one pole on the 
abdomen is the best method. 

In addition to the above the general health should 
be looked after and such drugs given as may be 
indicated. 

From what has been said in regard to other 
causes, such as stricture, tumors, adhesions, painful 
or hypertrophied sphincter muscles, nothing more 
need be said as the diagnosis suggests the treatment. 

There is probably no one thing so important as 
getting the bowels back into the habit of moving at 
a regular time daily; the patient should be taught 
that this is the most important event of the day, and 
should never under any conditions be neglected. He 
should be told to exercise in the open air as much 
as possible ; simply a stroll around the block will do 
no good, but a brisk walk of a mile or two every day 
will be of great benefit ; bicycle or horseback riding, 
boating, or anything that will bring all the muscles 
of the body into action, start the blood to flowing 
n:ore freely through the sluggish veins and capil- 
laries, and open the pores will often do wonders. 
Frequent baths with brisk rubbing is of benefit. 

Drugs should be used only very sparingly, and 
not at all if it is possible to avoid it; those recom- 



CONSTIPATION. 8i 

mended as being beneficial in this condition are very 
numerous, and no one need lack for variety. I be- 
lieve that the mild alkaline mineral waters taken 
morning- and evening do no harm, even if taken for 
a long time, or until they, with other means, bring 
about a normal condition of the bowels. 

Many times a glass of cold water taken at bed- 
time, and a hot one containing a very small amount 
of sodium phosphate or magnesium sulphate an hour 
before breakfast, are of benefit. If a more decided 
effect is necessary, the following plan has proven 
very beneficial with me. Begin wuii the minimum 
daily amount of Fl. Ext. Cascara Sagrada rec[uired 
to get at least one bowel movement ; give the amount 
required in three doses, one before each meal. 

Suppose it requires ten drops three times a day 
to produce the desired result ; this is given for a week^ 
when one drop is omitted from each dose; the 
amount is decreased one drop each week until it gets 
down to nothing. If necessary this may be repeated, 
beginning the second time with about one-half the 
original dose, or in the case supposed, five drops. If 
other measures have been carefully attended to, the 
patient ought now to discontinue the medicine 
entirely. 



82 RECTAL DISEASES. 

There is a small pill on the market having the 
following formula that I have used with success in 
the way just spoken of, using the proper number of 
pills instead of the drops of cascara sagrada. 

Ext. Aloes purificat gr. I-I2th 

Ext. Nucis Vom gr. i-24th 

Ext. Belladonnae gr. i-iooth 

Oleoresin Capsici gr. i-500th 

Pulv. Ipecac gr. i-i20th 

Misce. Ft. pil. No. i. 

I think that the above pill is improved by adding 
to it a small amount of Cascara Sagrada. 

In cases of pregnancy, where it seems to be nec- 
essary to give something for a long time, aiming to 
keep the patient in condition until after parturition, 
or in chronic diseases, where it is not thought best 
to try to effect a radical cure, the following formula 
is a most excellent one : 

Cascarin gr. i-4th 

Aloin gr. i-4th 

Podophyllin gr. i-6th 

Ext. Belladonnae gr. i-8th 

Strychnin Sulphat gr. i-6oth 

Gingerine gr. i-6th 

Misce. Ft. pil. No. i. 

gig"- Cive one or two at bedtime as required. 



. CHAPTER IV. 

FECAL IMPACTION 

Accumulation of Fecal Matter — Diarrhoea from Irritation — 
Causes — S^^mptoms — Diagnosis — Constipation — Treat- 
ment — Softening and Breaking up of the Masses — Re- 
moving it Mechanically — Cathartics Harmful — Injection 
of Water useless — Injection of Oxgall, of crude Petrol- 
eum, of other Mixtures — Massage — Vibration — Mechan- 
ical Methods. 

This means an accumulation of fecal matter in 
the intestinal canal, but more often in the cecum, sig- 
moid or rectum. 

It is usually a mass that has gathered slowly, and 
during the time that it has been accumulating there 
is often a diarrhoea caused by the irritation which 
it produces. 

It is caused by about the same things that pro- 
duce constipation, but the beginning is sometimes 
a mass of seeds or other foreign bodies which act 
as a nucleus around which the mass gathers, much 
the same as a stone is formed in the bladder, In 

83 



84 RECTAL DISEASES. 

fact, some of these, especially those of long stand- 
ing, seem to be made up partly of lime salts. Large 
amounts of coarse, woody fibre or food with much 
waste matter, concretions formed by eating a great 
deal of magnesia, as is sometimes done for the re- 
lief of acidity. Foreign bodies lodged in the colon, 
stricture, etc., are some of the things that may bring 
it about. 

As spoken of under coiistipation, non-attention to 
the calls of nature due to ignorance, paralysis of the 
bowels and intestinal atony may act as causes. 

Symptoms and diagnosis. Constipation is likely 
to be the first symptom noticed by the patient and 
this is followed, usually by a chronic and most an- 
noying diarrhoea with great straining at stool and 
the protrusion of congested angry looking masses 
of mucus membrane much resembling hemorrhoids 
and frequently mistaken for them. 

Treatment. This consists in softening the mass 
so that it may be broken up and passed in the usual 
way, or removing it mechanically under anaesthesia. 
In my opinion it is useless to give cathartics and it 
may do harm. About the only remedy that has 
seemed to me to be of any benefit is some bland non- 
cathartic oil and glycerine, I have given a mixture 



FECAL IMPACTION. 85 

of one-fourth glycerine and three-fourths oHve oil, 
apparently with good results. 

Some treatment from below will be required in 
the vast majority of cases. It might as well be un- 
derstood at the beginning that injections of water, no 
matter how given, or at what temperature, are use- 
less. 

Inspissated ox gall is said to act o nthe mass and 
cause it to disintegrate and pass away. This should 
be injected with the patient in the knee-chest posi- 
tion and if the impaction is in the cecum enough wa- 
ter should be added to force the ox gall to the proper 
place. An injection of a pint or more of crude 
petroleum oil with the patient in the knee-chest posi- 
tion will do wonders in many instances. 

The so-called Noble's enema may be used in the 
same way. The composition is as follows : 

Magnesium Sulph oz. 2 

Glycerine oz. 2 

Turpentine oz. ^ 

Aqua, qs. ft oz. 16 

This should be injected with the patient in the 
knee-chest position and retained as long as pos- 
sible. In addition to any or all of the above meas- 



86 RECTAL DISEASES. 

ures, massage or vibration over the abdomen may 
be used, and often to great advantage. 

If the above methods fail there is nothing to do 
but put the patient under an anaesthetic and break 
up the mass. If it is in the rectal pouch which is its 
usual location this is not hard to do. A scoop such 
as is used to remove gall stones does very well for 
this purpose. 

The sphincter should be well dilated and even 
then it is at times no easy task to remove the mass. 
In female patients two fingers in the vagina will help 
to steady the parts and hold it firmly against the sa- 
crum. In case the collection is too high to be 
reached from below perseverance along the line indi- 
cated will almost surely succeed in getting it to 
pass into the rectal pouch, wdien it can be removed 
as suggested. 



CHAPTER V. 

RECTAL ALIMENTATION 

Early Beliefs— Nourishment by Absorption — When Rectal 
feeding becomes necessary — The necessity of great care 
and gentleness — Methods of Injection — Position — Care of 
Tubes — Where the Food should be deposited — The 
quantity of food — Intervals between feeding — Kind of 
foods for rectal feeding. 

It has been known almost from the earliest his- 
tory of medicine that certain kinds of food intro- 
duced into the rectum would sustain life for many 
days or even weeks, although none was put into the 
stomach. The early writers seemed to think the rec- 
tum had some digestive power much like that pos- 
sessed by the stomach, but we now know that this 
is not true and that all the nourishment put into it 
is taken up by absorption into the rectal veins. 

In certain diseases of the stomach, especially ul- 
cer, it may be absolutely necessary that the organ be 
given complete rest and in order to do this rectal 
feeding becomes necessary. I do not wish to go 

87 



88 RECTAL DISEASES. 

into this in detail as it would require too much space, 
hut will give a few points that may be of benefit. 

In the first place the greatest care and gentle- 
ness must be used to keep the rectum clean and free 
from irritation. As often given with metal or hard 
rubber nozzle and a fountain syringe the mucous 
membrane soon becomes sore and the whole rectum 
irritated and the patient becomes nervous to such an 
extent that it has to be discontinued. 

METHOD 01^ INJECTION. 

The best position for the patient is on the left 
side with the hips well elevated. 

For an adult a large soft rubber catheter is the 
best tube to use. If the feeding is to be continued 
for some time the rectum should be washed out 
once a day with warm boracic acid solution, imme- 
diately after which a nutrient enema may be given. 

The same tube may be used for both purposes, 
but for the cleansing douche a fountain syringe may 
be used, while for the nutrient enema a hard rubber 
piston syringe is to be preferred. 

The most rigid rules should be observed in re- 
gard to the care of not only the tube, but the syringe 
and everything used that they may be kept in an 
aseptic condition. 



RECTAL ALIMENTATION. 89 

AMien the patient is in position and the food 
warmed to a httle higher temperature than the 
blood, the catheter should be dipped in warm olive 
oil and carefully pushed through the sphincters. No 
force should be used and the catheter should be al- 
low^ed to go in nearly full length. The food is now 
sucked up into the syringe and after all air is ex- 
pelled, is connected to the catheter and very slowly 
and quietly injected. 

It is not absolutely necessary that the food be 
deposited above the rectal pouch and in fact the ca- 
theter often curls up and goes no higher than this 
point, but if it can be injected into the sigmoid with- 
out more effort than has already been given, it is 
best that this be done. 

It is now believed by some physiologists that 
there is an upward current going on all the time 
along the walls of the colon, and that even under 
normal conditions while the main bulk of the ma- 
terial in the colon is flowing toward the rectum, 
there is constantly going on this return flow of the 
more liquid portions and that anything that may be 
of value from a nutritive point of view is picked up 
by the veins. If this be true, it is possible that any 
fluid injected into the rectum may be at once carried 



06 RECTAL DISEASES. 

upward in this current and absorbed from the bowel 
above and not from the rectal cavity. 

The quantity used should not, as a rule, be more 
than four to eight ounces for an adult and if the 
rectum acts well this may be repeated in four or 
five hours, but if there is much irritation the time 
should be extended to eight hours and the enemas 
made somewhat larger and more nutritious. 

SUBSTANCES TO BE USED. 

Milk is the one food that may be depended upon. 
It should be pancreatinized and very rich in cream. 

Eggs beaten up with milk and a little pepsin 
and salt added may be used. 

Meat juice, scraped meat and various things 
along this line may be tried. 

The following is a fair sample of mixtures that 
may be used. 

Milk . . . oz. 6 

Eggs 2 

Sodii Chlor oz. i 

M. Predigest with pancreatin gr. 5, Sodii Bi 
Carb gr. 15. Keep warm until slightly bitter and 
use. 



CHAPTER VI. 

HEMORRHOIDS 

What Hemorrhoids are— Causes of Hemorrhoids — More 
frequent in men than women — Classification — External — 
Internal — Symptoms and Diagnosis — Capillary — Ven- 
ous — Thrombohc — Cutaneous or connective tissues — 
Treatment — Palliative treatment — Diet — The general 
health — Drugs — Dilatation — Divulsion — Injection method 
of treatment — Methods of operating — Formulas for injec- 
tion treatment — When the injection method should not be 
used — Other methods of cure — Operations — Electrolysis. 

Hemorrhoids or so-called "piles" are tumors, sit- 
uated at the muco-cutaneous junction of the anus or 
beneath the mucus membrane of the rectum and 
composed of a dilated blood vessel or a mass of di- 
lated blood vessels united by connective tissue, or 
to a clot of blood outside the blood vessel caused by 
a ruptured vein. 

This does not, strictly speaking, include the so- 
called tag of skin, but as they are usually the remains 
of the thrombotic variety or some irritation of the 
parts they would come under the above definition, 

91 



92 RECTAL DISEASES. 

when they first become of sufficient importance to 
require the care of the physician. 

Cause of Hemorrhoids. Nearly everything imag- 
inable has been assigned as the cause of this dis- 
ease, and yet it seems to occur regardless of any 
apparent reason. I have seen persons who were in 
perfect health otherwise, afflicted with the disease in 
its most aggravated form, while others who seemed 
to do everything possible to produce an attack es- 
caped entirely. 

Still there are some things that may safely be 
accepted as causes. In the first place we find that 
age has much to do with it as the disease seldom oc- 
curs in early life. Children are not often affected, 
although it is possible that this might occur. Cases 
are reported in children less than a year old. Many 
things that are known to produce the disease do not 
occur in childhood, such as menstruation, child-bear- 
ing and the excessive exercise of the genito-urinary 
functions. 

It has been thought that heredity had some in- 
fluence in causing the disease. While I am not able 
to deny that this is so it seems to me that it is true 
in a general way only. If a mother is in poor health 
during her period of gestation and suffers from 



HEMORRHOIDS. 93 

anemia, constipation and the hemorrhoidal troubles 
that so often accompany this condition, it is only rea- 
sonable to think that her offspring may be affected 
the same way to a certain extent, but because a 
child's father or mother had some rectal disease at 
some remote period of life is no reason why the child 
should be afflicted in the same way. 

This is purely a local disease and there is no con- 
stitutional effect upon the system that may be handed 
down from father to son, as there is in syphilis and 
some other diseases. Where hemorrhoids appear in 
successive generations it is more likely that the chil- 
dren have lived in about the same way their parents 
did before them and the conditions that produced 
them in the parents have reproduced them in the 
children. I have on more than one occasion treated 
father and son and have known the disease to have 
been present in three generations. 

It is generally believed that this disease is more 
frequent in men than women. Men lead a rougher 
life than women and are more subject to severe mus- 
cular effort and are more likely to over eat, and 
drink alcoholic liquors to excess, and yet on the other 
hand, women are subject to a monthly engorgement 
pf the pelvic organs, and child-bearing ig known to 



94 RECTAL DISEASES. 

be a most prolific cause of the disease. So, on the 
whole, it seems to me that the chances are about 
equally balanced. One reason more men- seem to 
be afflicted than women is because the latter will 
not seek medical aid unless they are in a very serious 
condition, while men are more likely to go to the 
doctor upon the first appearance of the trouble. 

There is no doubt that occupation and manner 
of living have much to do in the production of this 
disease. Persons who are constantly on their feet, 
especially if at the same time they are engaged in 
some hard labor, as railwa}^ firemen, engineers, etc., 
are very likely to be affected. When this is com- 
bined with irregular meals we have a most prolific 
cause of the disease. 

On the other hand, persons who lead a sedentary 
life and are constantly at their desk are very prone 
to the disease because of the lack of exercise with 
its attendant indigestion and constipation. Those 
who habitually gorge themselves with large amounts 
of food and liquor are very likely to have hemorr- 
hoids and it is not uncommon with some people to 
have an attack follow a banquet where much rich 
food and drink are taken. 

Probably the most essential cause of the disease 



HEMORRHOIDS. 95 

is an anatomical one. This consists in the erect pos- 
ture of the human being. Man is the only animal 
who stands erect. This posture throws the weight 
of the entire column of blood from the hemorrhoidal 
veins into their terminal portion in the rectum and 
a constant dilatation is the result. If the veins were 
supplied with valves, this would relieve this constant 
congestion to a certain extent, but there are no 
valves. 

The veins pass from the peritoneal side of the 
bowel through button-hole like slits to the mucous 
side about a finger's length above the anus and then 
divide into smaller branches and drain the lower end 
of the bowel. This peculiar anatomical condition is 
no doubt the most prominent cause of hemorrhoids, 
as it may, under certain conditions, such as constipa* 
tion, pregnancy or retro-version of the uterus, shut 
off the calibre of the veins and cause an engorgement 
and excessive dilatation of their lower ends. As the 
arteries are of different construction and do not pass 
through these openings they are not occluded in the 
way the veins are. As a result the blood flows into 
the parts easily, but has difficulty in getting out, and 
dilatation and hemorrhoids are the result. 

Classification. In a general way hemorrhoids 



96 RECTAL DISEASES. 

are divided into two general divisions, viz. : external 
and internal, and these are each subdivided into two 
kinds as follows: Internal — Venous and Capillary. 
External — Thrombotic and Cutaneous. We often 
hear of various other kinds as blind, bleeding, itch- 
ing, mixed, inflammatory, etc., but they are really 
all included in the above classification. 

By internal we mean those above the sphincter 
muscles and which originate from the superior hem- 
orrhoidal vein, and by external is understood those 
below the sphincter that are from the inferior hem- 
orrhoidal veins. There is a mixed variety which is 
really a combination of the internal and external 
and need not be considered separately. 

Symptoms and Diagnosis. Taking up each va- 
riety separately we will first consider the internal. 

Capillary Hemorrhoids. These are simply a dilat- 
ed condition of the terminal ends of the blood ves- 
sels and often if left untreated merge themselves 
into the venous form. While still small enough to be 
called capillary they do not project into the calibre 
of the bowel to any great extent and for this reason 
are difficult to locate. They are really more like a 
naevus or erectile tumor and often have the appear- 
ance of a ripe strawberry. The covering over the 



HEMORRHOIDS. 97 

dilated vessels is so thin that the passage of fecal 
matter over it causes it to rupture and a loss of blood 
is the result. 

This constitutes practically the only evidence of 
the disease, as there is no pain, protrusion or any 
other symptom except the loss of blood. Often the 
patient is entirely ignorant of the fact that blood is 
being lost and great anemia results which does not 
yield to treatment by iron, arsenic, etc. I have had 
patients who were so weak from loss of blood that 
they could scarcely walk alone and who had been 
treated for months by internal remedies with no 
thought by themselves or by their doctor that the 
trouble all came from capillary hemorrhoids. Al- 
though but a small amount of blood is passed each 
day, nature cannot reproduce it as fast as it is lost. 

Venous Hemorrhoids. In this form the capil- 
lary network of blood vessels has disappeared and 
protrusion is the chief symptom. It is true that the 
venous variety often bleed but it is from the pres- 
sure of the temporarily strangulated tumor which 
is protruded just far enough to allow the sphincter 
muscle to shut off the return flow and blood is 
forced through the walls of the veins. The patient 
is usually greatly relieved after this bleeding occurs. 



98 RECTAL DISEASES. 

As a rule this form of the disease does not need 
treatment until the tumors get large enough to pro- 
trude, but sometimes there is a train of symptoms 
that are characteristic of the disease before the pa- 
tient realizes the nature of his complaint. Kelsey 
enumerates these symptoms as follows : ''A feeling 
of discomfort in the rectum, and a sensation that it 
has not been thoroughly emptied after stool, which 




Pig. 11. Prolapsed internal hemorrhoids, 
induces the patient to sit and strain for a long time ; 
difficulty in micturation; diminished sexual pow- 
er and desire ; pain in the genitals, loins and thighs ; 
and formication in the lower extremities." 

In case the tumors are not large enough to pro- 
trude at stool it is often a difficult matter to dis- 
cover them as they recede among the folds of mu- 
cous membrane and often they cannot be felt by the 
finger or seen through a speculum. Fortunately it 



HEMORRHOIDS. 99 

is seldom that treatment is required unless they pro- 
trude or bleed. There is really only one sure way 
to diagnose this kind of hemorrhoid and that is to 
have them forced out where they may be plainly 
seen. If necessary an enema of warm water should 
be given which will enable this to be done quite eas- 
ily. There is scarcely any other condition for which 
this could be mistaken unless it might be prolapse. 
The latter comes down around the entire circumfer- 
ence of the bowel, making a complete ring, while 
hemorrhoids consist of one or more distinct tumors 
all more or less congested, solid and angry looking. 

Thrombotic Hemorrhoids. This is caused by the 
rupture of a small vein and the extravasation of 
venuous blood into the connective tissue. It often 
comes on without any apparent cause. The patient 
will feel an uncomfortable sensation at the verge of 
the anus and upon- examining himself will find a 
small lump which he tries in vain to push above the 
sphincter muscle. If he finally succeeds, he finds 
that it will not remain there but at once comes out 
where he first found it. 

In fact it will neither stay clear in or clear out, 
but persists in remaining where it is grasped by the 
muscle, which renders it very painful. In fact, pain 



I oo RECTAL DISEASES. 

is the essential feature and there seems to be noth- 
ing that the patient can do or any position that he 
can assume that in any wSlj alleviates the pain. If 
seen soon after it occurs, it will be found to be soft, 
of a bluish black color and very painful. If exam- 
ined a few days later, it will not be quite so pain- 
ful, and will feel like a shot or other hard substance 



Fig. 12. A typical thrombotic hemorrhoid. 

beneath the skin. If allowed to take its own course, 
it will be absorbed and carried away or suppurate 
and form a small marginal fistula. 

Cutaneous or Councctive Tissue Hemorrhoids. 
These are really fleshy skin tabs and consist of the 



HEMORRHOIDS. loi 

remains of thrombotic tumors that have been al- 
lowed to absorb, or from some irritation about the 
edge of the anus. The condition is often found after 
some more serious disease of the bowel higher up. 
In fact it used to be considered a prominent symptom 
of stricture or ulceration of the bowel. It is said by 
some that tliey are indicative of syphilis. They are 
not of much importance unless inflamed when they 
become quite painful. 

treatme:nt. 

The treatment of the capillary variety consists in 
obliterating the dilated blood vessels and producing 
an eschar instead. Probably nothing accomplishes 
this better than the application of fuming nitric acid. 
No cocaine is needed as a rule, although if the pa- 
tient is ner^•ous or very sensitive to pain, it may be 
used. 

Dip a glass rod in the acid, and while the spot is 
exposed through a speculum, apply the acid, rubbing- 
it in well but being careful to not allow it to drop 
upon or touch any other spot. After th.e acid has 
been applied, put on a solution of soda to neutralize 
any excess that may 1)e present. This causes but 
little pain and requires no after treatment. They 



I02 RECTAL DISEASES. 

may be destroyed by exposing the bleeding area and 
applying the red hot thermo-cautery. 

The best treatment of the thrombotic form is to 
take a small, very sharp, curved knife and make a 
free incision, much the same as would be done if 
opening an abscess, and turn out the clot. 

This is somewhat painful, and if it is desired to 
do a painless operation, dip a needle in pure car- 
bolic acid and touch the healthy skin at the margin 
of the swelling. This will anaesthetize a spot 
through which the hypodermic needle may be pain- 



.-^^K\^ 



Fig. 13. Tuttle's rectal speculum. Very useful in treating 
capillary hemorrhoids. 

lessly thrust just far enough to include all the bev- 
eled edge, when a drop of cocaine solution may be 
forced in ; after waiting a minute for this to have its 
effect, it is pushed in a little farther and more solu- 



HEMORRHOIDS. 103 

tion injected. In this way the swelHng may be filled 
with the solution and opened with absolutely no pain. 

x\fter the clot is turned out a pledget of cotton 
should be placed in the wound and left for twenty- 
four hours. It should be examined at this time to 
see that the cotton has not fallen out and a new clot 
taken its place. If this has occurred, it should be 
repacked, otherwise it should be syringed out with 
carbolized water, after which it will require no furth- 
er treatment. 

In case there is a redundancy of tissue, it is bet- 
ter to simply lift the tumor from its base with a pair 
of toothed forceps and make an elliptical incision 
around it, entirely removing not only the blood clot, 
but considerable of the surrounding tissue. If this 
is done, two or three fine silk sutures should be put 
in to draw the edges together. By putting them 
quite deep they may be inserted before the tumor is 
cut off and at once tied securely. Two or three days 
later they should be removed. 

Either of these plans will give the very best re- 
sults, both to patient and operator, and the disease 
will be permanently cured in the shortest possible 
time, which need not exceed three or four days. 
Should the patient refuse even this little operation, 



I04 RECTAL DISEASES. 

there is nothing to do but apply lead and opium 
wash, together with hot or cold applications accord- 
ing to which gives the greater comfort to the patient, 
and wait for nature to absorb the clot, which in many 
cases requires two or three weeks. Or, should ab- 
sorption not occur, wait for a marginal fistula to 
appear, and treat the latter some time in the future. 

The treatment of the cutaneous variety consists 
in injecting the tumor with a solution of cocaine, 
lifting it from its base and cutting it off. Should 
hemorrhage be feared, a couple of ligatures may be 
placed under the tumor as directed in the thrombotic 
pile. 

Unless there is an unusually large number of 
them, no fear of stricture need be entertained, ex- 
cept if they be inflamed, in which case the swelling 
is deceptive and more tissue may be removed than 
is intended, resulting in an excess of cicatricial tis- 
sue and contraction. 

Should the patient seek relief during an attack 
of acute inflammation, it is better to use lead water 
and opium or other astringents until the attack has 
passed, and then operate. This operation is easy to 
perform, is entirely painless, and will give the utmost 
satisfaction to the patient. 



HEMORRHOIDS. 105 

THE PAI^LIATIVE TREATMENT OE HEMORRHOIDS. 

Sometimes it is necessary to treat persons who 
have piles, by other than operative methods. This 
is true in pregnancy, where operations are not usual- 
ly needed, as the disease will generally disappear 
soon after parturition; also in very old, feeble per- 
sons, or those who have some other chronic dis- 
ease, it is often best to keep them as comfortable as 
possible without trying to effect a radical cure. Much 
may be done if the patient is willing to do his part 
and carry out fully the directions given. 

The diet should be carefully regulated, and no 
food eaten that will leave a large amount of residue 
to fill the bowel and pass away as waste matter; 
the general health should be carefully attended to, 
and only food of the most nutritious and easily di- 
gested character given; this should contain such 
things as are known to prevent constipation, such 
as fresh fruits, rice, prunes, cereals, \'egclables. 
brown bread, meat broths, oyster soup, etc. If nec- 
essary a glass of some alkaline mineral water s'lould 
be taken night and morning, not to act as a cathartic, 
but to keep the bowel contents soft and non-ir- 
ritating. 



io6 RECTAL DISEASES. 

I know of no one thing that is of more benefit 
to these people than to have the bowels move the last 
thing before going to bed instead of in the morning. 
The recumbent position allows the blood to flow 
out of the hemorrhoidal veins easily and quickly, 
thus relieving the congestion, and by morning all ir- 
ritation has disappeared, and the day is passed with 
but little discomfort. On the other hand, where the 
action occurs in the morning the blood has to be 
forced in a perpendicular column, which at best is 
a difficult performance, and the pelvic contents re- 
main congested and the piles irritated all day. 

After tlie bowels move, a small amount of cold 
water should be injected to be sure the real cavity 
is completely empty. Often most excellent results 
are obtained by following this with equal parts of 
water and witch-hazel and retaining it. This has 
an astringent effect upon the dilated veins, and 
sometimes seems almost to be a curative, although 
the patient should always be informed that he need 
not expect a radical cure. 

Should there be a decided tendency to constipa- 
tion, medicines of a decidedly laxative character 
should be given. The following formulas have giv- 
en me good results : 



HEMORRHOIDS. iC^'j 

Sulphur Loti oz. i 

Potass Bitart oz. i 

Pulv. Sennae dr. 4 

Fl. Ext. Case. Sagrad dr. 2 

]\Iisce. Sig. Take a teaspoonful at bedtime. 
Also: 

Aloin gr. 1-4 th 

Strychnin gr. i-6oth 

Ext. Belladon gr. i-ioth 

Ext. Case. Sagrad gr. i 

Misee. ft. pil. I. 
Sig. One or two at bedtime. 
I believe it to be bad practice to be constantly 
introducing suppositories iuio the rectal cavity. They 
are said to "soften the xccal mass" and make it 
"mushy," but when it is remembered that the fecal 
mass is not in the sigmoid flexure except for a few 
minutes just previous to defecation, it is hard to 
see how it could be affected by drugs that do not 
extend more than a finger's length above the ex- 
ternal sphincter. 

It is true that in some especially old persons the 
rectal cavity is more or less filled with hard fecal 
matter all the time, but this is abnormal, and if 
washed out with cold water, as already advised, after 



ro8 RECTAL DISEASES. 

each bowel movement, it will be empty the greater 
part of the time. In some instances the fecal matter 
is dry and bard, being passed with difficulty and 
greatly irritating the anal canal. In such cases a 
half-ounce of sweet oil injected an hour before the 
bowxls move will do great good, not so much from 
softening the hard lumps as from its lubricating 
properties, by which they are covered with oil and 
the mucous membrane is softened and their passage 
made easy. If it seems that a more decided astrin- 
gent action is desirable, an ointment containing 
tannic acid may be used through a pile pipe two or 
three times daily. 

After studying this disease for years, I believe 
tlat tie palliative treatment outlined will keep pa- 
tients wlio suffer from piles in better condition than 
any other with which I am familiar. 

Dilafcifion. In old chronic cases of internal hem- 
orrhoids it seems a waste of time to expect a cure 
from dilatation of the sphincter muscle as the tumors 
will not in any way Ije diminished in size and the 
muscle will be weakened and put in a much poorer 
condition to hold the mass up than it was before. 
The condition in which a cure may be expected is in 

recent cases where the tumors are just forming and 



HEMORRHOIDvS. 109 

the irritated sphincter muscle grasps them so firmly 
that great pain is caused. Here a thorough dilata- 
tion or ratlier divulsion of the muscle will bring- 
about a cure for son:e time and often permanently. 

I am endeavoring to perfect a plan whereby this 
may be done in the office with cocaine anaesthesia 
and am able to do it in certain cases quite well, but 
in others it is not an entire success. This is by cata- 
phoresis. 

A pledget of gauze is soaked in a 10 per cent 
cocaine solution and wrapped about a specially de- 
vised copper rectal electrode. (See cut.) The gauze 
should extend over the enlargement so as to affect 
a portion of the skin outside the anus. This is now 
attached to the positive pole of a galvanic battery 
and a large moist pad attached to the negative pole 
and applied to the buttocks and about thirty milliam- 
peres turned on and kept going for ten minutes. But 
very little of the cocaine vvill get into the general cir- 
culation but the tissues will be saturated with it bet- 
ter than if injected hypodermically. 

Nitrous oxide gas w^orks nicely in these cases, 
but the apparatus is expensive and not often needed 
and most physicians do not have it in their office. 
In case neither of the above can be used, chloroform 



I JO RECTAL DISEASES. 

or ether are always at hand. As the muscle must 
be divulsed in case the ligature or clamp and cautery 
are used, it will be well to describe here how to do it. 




Fig. 14. Copper Electrode for producing anaesthesia of 
the sphincter muscles. 

By divulsion is meant the stretching of the 
sphincter muscles until they are temporarily par- 
alyzed so that any tumors or other abnormal condi- 
tions may be brought plainly into view^ 

It is not the intention to break the muscle and 
great care should be used in this regard. For this 
reason the A'arious dilating instruments are never 
used by me with the exception of a broad bladed 
bi-valve speculum which is used to begin the opera- 
tion, when my fingers or thumbs placed back to 
back are substituted. In this way I can feel the 
muscle yield and can direct the force intelligently 
and not have to depend upon a steel instrument. 

Th,e force applied should be directed in all direc- 
tions and slowly, the thumbs being changed to dif- 



HEMORRHOIDS. m 

ferent quadrants of the anal ring as dilatation takes 
place. If the muscle persists in contracting after the 
thumbs are removed the operation should be con- 
tinued until it ceases to do so. Caution should be 
used in doing this operation on old persons or those 
whose muscles are weak as there is a possibility of 
its causing incontinence, although it has never done 
so in my practice. 

THE INJECTION METHOD OE TREATING PIIvES. 

This method is very much misunderstood by the 
profession, and many think that it should never be 
used, urging that it may cause sudden death, car- 
bolic acid poisoning, emboli, abscess, fistula, great 
pain, etc. 

I 'have never been able to learn of a death as a 
result of this treatment, and persons who make this 
claim have never, so far as I am concerned, been 
able to verify it other than by hearsay evidence. The 
other things such as abscess, etc., are no more apt 
to occur in the practice of qualified men than acci- 
dents are in the ordinary surgical procedures in 
the practice of the same men. It is Vv'ell known that 
the great surgeon. Sir Astley Cooper, lost a patient 
from hemorrhage in a ligature operation for piles, 



1 12 RECTAL DISEASES. 

and several others have been lost by good operators. 

I have seen complete stricture caused by the too 
free use of the cautery in hemorrhoid operations. I 
recently came near losing a patient from secondary 
hemorrhage following an operation for fistula. These 
accidents are not the fault of the method, but of the 
operator. I know that when this plan of treatment 
came out there were many accidents reported by 
Andrews, but this was by inexperienced men, and 
the same is true of any operation or new procedure. 
The first operations for the radical cure of hernia 
were nearly all failures : now they are nearly all 
successes. So it is not fair to compare this method 
as now done by reputable men with the results ob- 
tained ten or even five years ago. I do not wish to 
be understood as advocating this treatment in all 
cases, but that it has a field of usefulness, and in 
many cases is the very best procedure that can be 
adopted, is beyond question. I have used it in hun- 
dreds of cases, and in nearly every instance with 
the happiest results. 

Several years ago, in a paper read before the 
A'ledical Society of the Missouri Valley, I made use 
of the following words, and further experience has 
gi\en me no reason to change my v)pinion : "Patients 



HEMORRHOIDS. 



113 



suffering from internal piles do not, as a rule, con- 
sult a physician until the tumors have been formed 
for some time. They may have existed for a long 
time before their presence is known by the patient; 
but after an unusual amount of exertion, or a pro- 
tracted period of constipation, or too liberal indulg- 
ence in food or spirituous beverages, they suddenly 




Fig. 15. Proctoscope, or Sphincterscope, to be used for 
diagnosing piles, and to expose them to view so they 
may be grasped with forceps and drawn down. 

begin to protrude at stool. Now( when this occurs, 
they will nearly always be highly irritated and in a 
badly inflamed condition. Should the sufferer come 
to you at this time, he would not be a suitable sub- 
ject for the injection plan of treatment. But most 
of these patients buy some patent medicine to use 



114 RECTAL DISEASES. 

until the acute exacerbation is over, and then go 
along pretty comfortably until another attack oc- 
curs, and each one proves a little more severe than 
the one that preceded it, until the tumors get so they 
protrude at stool. 

"They generally remain more or less irritated, 
with the sphincter muscle highly sensitive. But oc- 
casionally, in a case of long standing, they will lose 
their soreness, and the constant friction and conges- 
tion will induce an induration of the tumor wall with 
a plastic exudation into the connective tissue be- 
tween the coats of the bowel, and a somewhat hard 
semi-fibrous tumor is the result. The constant pro- 
trusion causes the sphincter to lose to a considerable 
degree its contractile power, and they protrude very 
easily. The sphincter also loses its sensitiveness and 
tendency to spasmodic contraction, which is so pain- 
ful. In many cases the tumors are out of the body 
most of the time. These are the cases that are suit- 
able for injection. 

''In a recent work upon rectal surgery, by Drs. 
Goodsall and Miles, of St. Mark's hospital, London, 
the following language is used : 'In the third stage 
of hemorrhoidal formation, i. e., when the piles do 
not spontaneously return into the rectum, but re- 



HEMORRHOIDS. 115 

quire manual reduction, the prolapse taking place 
again upon slight exertion, such as standing or walk- 
ing, as well as with every act of defecation, bleed- 
ing is the exception, a discharge of rectal mucus tak- 
ing its place. When the surface of these piles is 
examined, the mucous membrane w^ill be found to 
have undergone considerable structural change at its 
lower part, the epithelial covering being considerably 
thickened, so as to closely resemble epidermis. This 
altered mucous membrane is very much paler in color 
than normal and when dried,- its surface does not 
readily become moist again. Moreover, gently rub- 
bing the surface will not always cause bleeding, as 
would occur with a pile covered with normal mucus 
membrane. Microscopically the epithelium of the 
altered m.ucus membrane is seen to iiave become met- 
amorphosed, the single layer of columnar cells hav- 
ing been changed into several layers of stratified 
epithelium.' " 

This describes exactly the form of tumor to 
which I belicAe this method adapted. When used 
in this kind of case, and in a proper manner, there 
will be but little pain or other complication, and the 
cure will be as complete as though done with the 
ligature, provided, of course, all the tumors are 



1 16 RECTAL DISEASES. 

treated. As more fully illustrating ni}^ meaning, I 
wish to describe two typical cases that I treated sev- 
eral years ago. 

Case I. I\Ir. H., a farmer, age about 50, had 
been a sufferer from internal hemorrhoids for sev- 
eral years. He had used about all the remedies that 
he had seen advertised, and nearly everything that 
his friends liad recommended, with negative results. 
When he can^e to me, he easily forced into view 
several large, solid, painless tumors, such as I have 
just described. The sphincter muscle was greatly 
relaxed, and the tumors were out most of the time. 
I injected one of the large tumors and one of the 
small ones with a 50 per cent solution of carbolic 
acid, and returned them into the bowel. No pain 
was complained of, and I could hardly make the 
gentleman believe that I had done anything. In 
about three weeks I injected the remaining tumors 
with the same result. These tumors have never 
been seen or heard from since and nearly ten years 
have passed since the operation. There was no 
pain or incon^'enience of any kind, neither was the 
patient hindered in the least from attending to his 
ordinary work about tlie farm. This was a typical 
case for the injection plan, and the most happy re- 



HEMORRHOIDS. , 117 

suits were obtained, but such cases are not tbe class 
most often seen. In fact, such strikingly typical 
cases are rather rare. I wish now to describe one 
that is just the reverse of the above. 

Case 2. Mr. W., also a farmer, age about 35, 
a neighbor of the foregoing, hearing how easily Mr. 
H. was cured, came to me, and upon examination, 
I found several highly sensitive tumors grasped by 
an irritated sphincter that was greatly given to spas- 
modic action. He would hear of no other treatment 
than that of injection, as had been done upon his 
friend. I explained to him that the cases were not 
the same, and that 'the operation in his case would 
be \xry painful ; but it was that or nothing with him, 
and so, much against my judgment, I operated by 
the injection method. 

I injected two medium size tumors the first 
time, and intended operating upon the others later. 
He still has the others, as I never had another op- 
portunity to treat them. In a few hours after the 
operation he began to have pain, and it continued 
until it became terribly severe, and required large 
doses of morphine. His suffering was very great 
and lasted for a long time. This is an extreme case, 
and should not have been treated in this way, at 



ii8 RECTAL DISEASES. 

the time that it was. A week or two of preparatory 
treatment might have put the patient in proper con- 
dition for this method, but it would have been bet- 
ter to have operated upon him by the hgature. 

mi:thod o:^ opekating. 

I do not think it best to disturb the patient's 
bowels by giving a cathartic unless he is constipated. 

If the preparatory treatment already described has 

been given, nothing further is needed, otherwise the 

diet may be limited for a day or two, and an enema 

of hot water used two or three hours before coming 

to the office. 

Have the patient lie on the left side, and if he 
can do so, strain the tumors outside the sphincter 
muscle. In case he cannot do this, an enema of 
warm water should be given, which will bring them 
plainly into view. I usually put some cosmoline on 
the exposed tumors and mucous membrane to pro- 
tect them from injury in case any of the acid acci- 
dentally runs over the outside. 

Having now filled the syringe with a fifty per 
cent solution of carbolic acid with equal parts of 
glycerine and water, the needle is thrust with a 
quick but gentle motion into one end of the long 



HEMORRHOIDS. 119 

axis of the tumor and the point pushed to the op- 
posite side, being very careful not to puncture the 
farther wall, as the medicine will run out of the open- 
ing made and do no good. Now, as the needle is 
being slowly withdrawn, the fluid is injected drop 
by drop. As this is being done a pale bluish color 
is seen to creep over the surface, and this is evidence 
that enough has been injected. 

Should the tumor be quite large, the needle, be- 
fore being -withdrawn, may have to be again pushed 
in at an acute angle to the first puncture, and a little 

of the fluid forced into the tissue at each side not 
previous^ reached. The injection should be made 
very slowly in order to allow the medicine to diffuse 

itself as far as possible through the. tissues, and a 

drop should be deposited just inside the puncture 

before the point of the needle is withdrawn in order 

to cauterize the opening and prevent the escape of 

the fluid. As the needle is quickly withdrawn, a 

pledget of cotton dipped in Monsel's solution is 

placed over the opening and held there for a short 

time to prevent the escape of the solution. 

Not more than one large tumor or two small 

ones should be treated at one time. It is best to 

operate upon the small tumors first, as they are more 



I20 RECTAL DISEASES. 

easily gotten at when held out by the large ones 
than they will be after the larger ones are removed. 
It is also easier for the patient, as the small tumors 
take up some room and the swelling is considerable 
in the large tumors, and the more space they have 
to expand the less pain will be experienced. 

The tumors are now well oiled and replaced with- 
in the bowel. This can be better done by the pa- 
tient than by the doctor, as he has learned by experi- 
ence how to go about it. The bowels should not 
be allowed to move for two or three days, and if 
necessary, a pill of camphor and opium should be 
given at such intervals as will prevent the desire to 
go to the stool. This will not only bind up the bow- 
els, but will relieve any pain that may be present. 
Should the bowels not move when it is desired that 
they should do so, a light laxative should be given; 
often a Seidlitz powder will be all that is necessary, 
or a small dose of castor oil, or broken doses of 
calomel. 

When the desire for an evacuation is felt, in- 
struct the patient to inject into the bowel an ounce 
of swxet oil, and the evacuation will be painless. I 
am not in favor of introducing suppositories of 
opium and belladonna into the bowel, as they only 



HEMORRHOIDS. 121 

act as a foreign body, and the only anodyne effect 
is from the absorption of the opium, which takes 
place to better advantage in the stomach. 

After the first treatment, or where one or more 
large tumors are treated, the patient should refrain 
from active exercise and remain at least part of the 




Fig. 16. Slide Speculum for injecting piles, treating ulcers, 

etc. 

time in the recumbent position. Still, I have operat- 
ed upon quite large tumors and had the patient go 
at once to hard labor; one worked the next day at 
digging a well, another at laying brick, and a third 
at sawing wood ; this w^as done, however, contrary 
to my orders. 



122 RECTAL DISEASES. 

The second operation should not be done for 
about two weeks, or possibly sooner, if all soreness 
has disappeared. The patient may not now be able 
to force any of the tumors into view, in which case 
the work will have to be done through a slide 
speculum. 

In this event an especially made needle about four 
inches long should be used. With these exceptions 
the injection will be made in the way already de- 
scribed, but great care must be exercised not to 
force the medicine under the tumor instead of into it. 
This accident is what causes abscesses, fistula, pain, 
etc., and should be carefully avoided. 

The reason that this method is said to be only 
palliative and not curative is that the tumors are not 
all reached, and six months or a year later one or 
more that were left become enlarged and prolapse. 
This is often the fault of the patient, as after one or 
two tumors are removed, he will feel so much better 
that he will not return for further treatment. For 
this reason I always warn patients that there is a 
possibility that one small tumor might possibly come 
down later and have to be removed, but that it will 
not be a return of the disease, and is easily and quick- 
ly remedied. 



HEMORRHOIDS. 123 

F'ORMUI.AS FOR INJECTION METHOD. 

The following formula is the one used more often 
than any other, and contains the essential ingredient 
of them all, viz., carbolic acid: 

Carbolic acid i dr. 

Glycerin i dr. 

Aqua Dest 2 dr. 

Misce. 

Dr. Agnew of San Francisco recommends the 

following, and has been used in my practice with 

good results : 

Sodii biborate ) 
Plumbi acet. j 

Glycerin i oz. 

Let this stand twenty minutes in a warm-water 
bath. After twenty-four hours add one full ounce 
of crystalized carbolic acid and two drams of dis- 
tilled water. The doctor also adds that "some make 
no allowance, in attempting to give my formula, for 
the increase in bulk of the glycerine occasioned by 
the addition of the half-ounce of solids, and direct 
that the ounce of carbolic acid be added to the full 
amount of the glyceride of lead and borax when 
made. By this inadvertence not much over thirty-five 



1 24 RECTAL DISEASES. 

per cent of carbolic acid is obtained. xAfter trying 
the acid in varying strengths, and watching its ef- 
fects, I lave concluded that not less than fifty per 
cent solution should be used." 

The following formula is one that was used for 
years by a traveling specialist. He sold the formula 
with directions for use for one hundred dollars. It 



V. 





Fig. 17. O'Neill's rectal speculum for injecting piles, treat- 
ing ulcers, etc. 

was given to me by a man who paid fifty dol- 
lars for it : 

Carbolic acid 4 dr. 

Plumbum acetat i dr. 

Salicylic acid 30 gr. 

Cocain mur 10 gr. 

Aqua dest. ) 

^1 . > aa, q. s. ft i oz. 

Glycerm ^ 



HEMORRHOIDS. 125 

IMisce. This should be used according to direc- 
tions previously given. 

NOTES ON THE INJECTION METHOD. 

Never inject piles that are inflamed or irritated. 
If they cannot be put in a quiescent state, use the 
ligature or clamp cautery. 

Never inject more than one large or two small 
tumors at once. 

Always have the intestinal canal, and especially 
the colon, unloaded before operating, and then bind 
up the bowel for two or three days. 

Never use a weaker solution of carbolic acid than 
twenty-five pei" cent. The object is to cauterize the 
tumor and absolutely destroy it, and this requires 
the stronger solution. A weak solution will often 
set up an inflammation that should never occur. 

Do not operate the second time until the soreness 
has disappeared from the first operation. 

If the directions given in the preceding pages 
are followed carefully, a cure may be expected in 
all suitable cases, which will constitute a majority 
of those that come for treatment, but the remain- 
der would better l)e operated upon by the ligature 
or clamp and cautery. 



126 RECTAL DISEASES. 

In this, as all other minor operations, it is the 
attention to technique and minor details that counts 
for success of failure, and unless the physician is 
willing to take the trouble to give attention to these, 
he will not be successful, no matter what method 
he uses. 

Use great care not to inject the fluid under the 
tumor instead of into it, otherwise complications 
may be expected. 

Opia!cs are as a rule not needed, but sliould they 
be required, give camphor and opium pill, or mor- 
phine hypodermically, and make hot applications to 
the anal region ; the pain, as a general thing, is of 
short duration, and does not in any way interfere 
with the cure any more than it does in other methods 
of operating. 

The odor that is often noticeable as the destroyed 
tumors come away is not the odor of sloughing tis- 
sue, but is due to the admixture of intestinal gases 
with the broken down and disintegrating mass as 
it is being thrown off from the surface of the 
bowel. 

OTHER METHODS OF CURE. 

OPERATION WITH CONTINUOUS SUTURE CEAMP. 



HEMORRHOIDS. 127 

Another way of operating upon internal piles is 
the following, and it is adapted to any case that is 
sufficiently developed to allow the tumors to be 
prolapsed so that they may be grasped with a pair 
of forceps. This is also one of the very best methods 
of operating upon the mixed sort of piles where the 




Fig. 18. Method of operating with Dr. Mason's continuous 
suture clamp. 

whole mass, both internal and external, can be 
grasped in the jaws of the forceps. 

First, saturate a piece of cotton in a ten per cent 
solution of cocaine, and by the aid of a small tubular 
speculum, insert it into the bowel, letting it ext'end 
from the rectal pouch to the external sphincter. Al- 
low this to remain for about ten minutes, and it will 
partially remove the sensibility from the tumors so 
that they may be handled without pain. Now, either 
have the patient strain them out, or by means of a 
proctoscope, or with a slide speculum and forceps, 



128 RECTAL DISEASES. 

draw them to the outside, taking the large one first. 

When the tumor has been exposed to view, seize 
its base, just tight enough so it wih not shp, but not 
so tight as to cut off the circulation, with the author's 
continuous suture clamp. Now inject the tumor as 
full as it will hold of a four per cent solution of 
cocaine. After allowing this to remain for a minute 
or two, the clamp is closed as tightly as possible, and 
the tumor cut off close to the upper surface. 

A medium size catgut is now threaded into a 
curved needle and passed through under the extreme 
upper end of the clamp, and a second stitch is taken 
so that it includes the first one in its grasp and 
serves to hold it from slipping, or a perforated shot 
may be clamped on the upper end which will answer 
the same purpose. The needle is then passed under 
and over the clamp at intervals of about a quarter 
of an inch until the lower end of the cut tissue is 
reached, being careful not to draw the ligatures 
tight. 

The upper end of the ligature is now^ seized with 
a pair of artery forceps, the clamp removed, and 
tension made upon the lower end of the ligature, 
which wdll draw the stitches into place and securely 
close the wound. A knot is made in the lower end 



HEMORRHOIDS. 129 

or a shot clamped on, and the remainder of the Hg- 
ature cut off. Ah the tumors may be operated upon 
at one time, or if preferred, they may be taken at 
intervals of a couple of weeks. 

This is one of the most satisfactory operations 
that I know of, as it is perfectly safe, has no com- 
plications, is adapted to any form of pile, provided 
only that it can be reached, and can be performed 
by any physician without assistance, and with but 
little trouble. If but one tumor is to be operated 
upon, the patient need not go to bed, or even stop 
his ordinary work. There will be but little pain, 
and an opiate is seldom recjuired. The bowels should 
not be confined, but allowed to move regularly, and 
the patient irstructed to bathe the parts often with 
warm carbolized water. 

OPERATING WITH NOTCHED CIvAMP. 

Another operation that has proven satisfactory 
is performed exactly as the one that has just been 
described, except that a clamp is used with a notched 
edge extending one-eighth of an inch above the 
jaws, through which ligatures are passed, and each 
tied tightly, after which the clamp is removed. (See 
Fig. 19.) 



130 



RECTAL DISEASES. 



Either of these gives a clean, neat, surgical 
wound that is securely protected from hemorrhage, 
and which almost always heals by primary union. As 




Fig. 19. 



Showing method of operating with the author's 
notched clamp. 



the ligatures are catgut they need not be removed, 
but in operations where they can be easily reached, I 
prefer silk. Both of the above clamps may be had 
from the H. G. Penfold Co., Omaha. 




Fig. 20. Appearance of parts after continuous suture or 
notched clamp operation on hemorrhoids. 

Operation by Ligature, This is the oldest meth- 



HEMORRHOIDS. 131 

od of treating internal hemorrhoids that is known 
to surgery and is one of the very best. Probably 
more specialists in this line use it than any other 
method. It causes somewhat more pain than some 
other methods, but no one can question its safety, 
efficiency, or the permanency of the cure if properly 
done. 

My method is about the same as that described 
by Allingham. I think the bowels should be pretty 
well cleared before the operation and, to accomplish 
this, a good cathartic should be given the second 
night previous to the operation and followed by lib- 
eral doses of salts the following day. 

The evening before the operation one or more 
large, hot enemas should be given to clear the colon 
of all fecal matter. A sufficient number should be 
given so that the water returns clear. At bed time 
the patient should have a hot bath and unless there 
is some contra indication, a pill of camphor and 
opium which will stop the peristaltic action of the 
bowels and give a good night's rest. But little wa- 
ter should be given just previous to the operation 
and the bladder should be emptied just before going 
to the operating room. 

I am opposed to starving patients for a week be- 



1^2 RECTAL DISEASES 



fore operating as is sometimes clone, for, if they are 
at all weak, it is a severe shock and puts them in 
poor condition for the operation. If plenty of good 
nourishing' food such as milk, eggs, beefsteak, etc., 
is given up to the time of the first cathartic and then 
reduced to about one-third of the previous amount, 
the patient will be in good condition. 

The n:orning of the operation, no enema should 
be given or in fact anything done except to empty 
the bladder before the patient is brought into the op- 
erating room. In exceptional cases, if the patient 
is weak, I allow tl^em a small cup of coffee or broth, 
provided it is taken not less than an hour before the 
operation. 

The patient is now anaesthetized, placed on his 
back with the thighs well flexed on tl:e abdomen and 
the legs well flexed on the thighs and held in place 
by leg holders. I like this position better than on 
the side, but when operating where a proper table is 
not to be bad, the Sims position is satisfactory. 

Having now dilated the sphincters, as previously 
described, the lowest tumor is grasped and with a 
pair of sharp scissors divided from below so that it 
is attached by the vessels and mucous membrane 
only. There is no danger in this as all the vessels 



HEMORRHOIDS. 133 

large enough to bleed seriously are in the upper part 
of the tumor. A stout ligature is now placed around 
the remaining portion and tied. Each tumor is in 
turn treated in the same way. 

In case a tumor is very large a double ligature 




Fig. 21. T forceps, to be used for grasping hemorrhoidal 
tumors. 

should be passed through its center by the aid of a 
needle after which the needle is cut off and each half 
of the ligature tied around the corresponding half 
of the tumor. For the large tumors, ligatures of 
plaited silk should be used and it sl.ould be strong- 
enough so that it cannot be broken by pulling. Small- 
er sized tumors require smaller ligatures and care 
must be exercised that sufficient force is not used to 
make the thread cut the base of the tumor entirely 
off. After all have been tied, most of the tumor 
should be cut away, leaving only enough to be sure 



134 RECTAL DISEASES. 

the ligature will not slip off. A stream of water is 
now run over the field of operation to see that there 
are no bleeding points and a little sterile gauze 
packed about the stumps of the tumors as they re- 
cede above the sphincters. I like this better than 
a tube as it checks all oozing and does not cause any 
pain. A pad and T bandage should now be applied, 
the patient given one- fourth grain of morphine and 
put to bed. 

On the following day the outside pad should be 
changed but the gauze put among the ligatures 
should not be removed, but allowed to come away 
with the first bowel movement. 

A dose of castor oil should be given the third 
day and repeated as found necessary until the bowels 
move. No more should be given until the patient 
gets up. Many male patients are unable to empty 
their bladder after this operation. If the caution 
previously given, to not give them any water for a 
few hours previous to the operation and then not 
allow them to try to empty the bladder for from 
twelve to twenty hours, is observed, they will gen- 
erally succeed, but if they try and fail, the catheter 
will have to be used and in some cases it will be 
necessary to use it in spite of all precautions. 



HEMORRHOIDS. 135 

I think it all right for the patient to get on his 
feet to empty the bladder the first time, as, often 
they can succeed in this way, where they could not 
while lying down. It is also just as well for him 
to use the commode for the first bowel movement 
and if an ounce or two of warm oil is injected into 
the bowel just previous to the movement, there will 
be but little if any pain. It is always best to inject 
a pint of warm boracic acid solution after the bowels 
move to wash out any remaining fecal matter and 
clotted blood. As a rule, my patients do not receive 
more than one or two doses of morphine but, if it is 
necessary, I do not hesitate to give enough to keep 
them comfortable. 

The ligatures will come away in from five to 
eight days and about this time a little blood may be 
passed, but it should cause no alarm as it will soon 
cease. Occasionally a ligature may not be tied 
tight enough to destroy the stump and will not come 
away without assistance. Should this occur, it may 
be carefully exposed through a speculum and re- 
moved. 

Clamp and Cautery Operation. As Kelsey is the 
most prominent advocate of this method, I will give 
his description of the operation in his own words. 



136 RECTAL DISEASES. 

The preparatory treatment is the same as already 
described. 

"As a rule the patient is etherized, in order to 
permit a free dilation of the sphincters. The tu- 
mors are next seized and removed one by one. No 




Fig. 22. Galvano cautery. 

speculum is necessary for this, but if one be used 
the large Sims rectal speculum is the best. Tlie tu- 
mor is seized with forceps and held out of the anus, 
while the base at the juncture of the skin and mucous 
membrane is divided as in the ligature operation, 
and the clamp applied to what remains of the ped- 
icle in the sulcus thus made. The forceps are next 
detached, the tumor cut off with the scissors (but 
not so short but that a good, firm stump remains), 
and the cautery is then taken from the assistant, 
whose sole duty it should be to have it always ready, 
and applied thoroughly to the stump of the hemorr- 



HEMORRHOIDS. 137 

hoid. No haste should be used in this step of the 
operation. The pedicle should be thoroughly charred 
with the platinum at a red heat. 

"When this has been done the clamp may be 
loosened, without being removed, to see if any ves- 




Fig. 23. Sims' rectal speculum, as modified by Van Buren. 
If any speculum is needed this will be the most satis- 
factory in the cautery operation. 

sel in its grasp is still inclined to bleed; and if a 
bleeding point appear, it is again tightened and the 
cautery is again applied. Thirty seconds is an abun- 
dance of time for each tumor. The secret of suc- 
cess in this operation is found just here. If all the 
cut surface is thoroughly cauterized while the clamp 



138 RECTAL DISEASES.' 

is on, there can be no hemorrhage ; but if more sur- 
face is cut than is cauterized, hemorrhage may rea- 
sonably be expected and the operator is to blame. 
Thoroughly cauterize the entire incision, except the 
initial one made before the clamp is applied, and 
trust nothing to the clamp or to nature, is the advice 
I always try to impress most strongly upon those 
studying this operation. 




Fig. 24. Clamp for cauterj^ operation on hemorrhoids. 

"When all the piles have been removed, the 
stumps will naturally retract within the sphincter 
and no dressing will be necessary. 

''The thing most difficult for the unpracticed 
operator to understand is at just what point to ap- 
ply the clamp ; and this can best be learned by ex- 
perience, as it really constitutes the delicate point in 
the operation. There is no difficulty when the tu- 
mor is an internal one arising fairly from the mu- 
cous membrane aboA'e the sphincter, and not involv- 
ing the skin of the anus. In such a case the clamp 



HEMORRHOIDS. 139 

does not implicate the muco-cutaneous junction at 
the anus, and removing too Httle tissue will not leave 
unsightly and annoying tags of skin, nor will remov- 
ing more than is necessary result in cicatricial con- 
traction to a serious extent. But where the margin 
of the anus tends to roll over, considerable experi- 
ence is necessary to learn just how much tissue to 
include in the clamp. 

"When it is necessary to divide the skin of the 
anus with the scissors before applying the clamp, 
there will be a little bleeding, which is easily stopped 
by a compress and bandage ; but when the clamp 
is applied only to parts covered by mucous mem- 
brane, and used without any preparatory cutting, 
the operation is almost bloodless, and under any cir- 
cumstance it is unnecessary lo soil more than a single 
towel. This is a great desideratum in cases of enfee- 
bled patients, besides enabling the operator to have 
his wounds perfectly dry without the use of any 
lint or other dressing. 

"No dressing of any sort is necessary after the 
clamp operation, except a pad of gauze covered with 
vaseline, and a T-bandage applied for a few min- 
utes to arrest oozing from the preliminary incisions 
in the skin. If the patient seems to be doing well 



140 RECTAL DISEASES. 

and complains of no untoward symptoms, the parts 
need not be examined for ten days, and all that is 
required is cleanliness to the wound. 

''The bowels should be confined for forty-eight 
hours, and about thirty-six hours after the opera- 
tion — in other words, at night of the following day 
— they should be encouraged to act ]:iy a slight lax- 
ative, either a pill or a saline. A single dose will 
gererally be sufficient, and when the time comes 
for tie bowels to move, an enema of water should be 
thrown into the rectum to facilitate Ih.e passage. In 
this way an almost complete clearing out of the 
rcc'Um is secured on the second day. The patient 
dreads this first motion, but is agreeably disappoint- 
ed, often being surprised that he has much less pain 




Fig. 25. Gant's clamp for cautery operation on hemor- 
rhoids. 

than his hemorrhoids caused him in each passage be- 
fore they were removed." 

Electrolysis. Good results may be expected in un- 



HEMORRHOIDS. 141 

complicated cases by the use of electricity. The tu- 
mors are brought into \dew and two or three ordi- 
nary sewing needles mounted in a suitable holder 
and attached to the negative pole of the galvanic 
battery are thrust into each one separately after 
which the positive pole is placed on the buttocks and 
a current of ten or twelve milliamperes turned on. 

After a few minutes the bubbles of hydrogen gas 
will be seen escaping around the needles. After this 
occurs to a well marked degree the current is turned 
off and the needles removed. As a rule about five 
to ten minutes is long enough to keep the current on. 
One application to each tumor is generally sufficient 
but if very large it may be required twice. The tu- 
mors do not slough but slowly shrivel up and dis- 
appear. 



CHAPTER VII 



ABSCESS 

Seat of suppuration — Pus — Results — Fistula Abscess — 
Etiology — Constitutional conditions — Varieties of ab- 
scess — Subcutaneous or marginal abscess — Ischio — 
Rectal abscess — Submucous abscess — Pelvi — Rectal ab- 
scess — Symptoms and diagnosis — -Treatment — Post 
operative treatment. 

The perineal rectal and immediate surrounding 
tissues, are the seat of suppuration more often than 
any other region of the body. Tlie anatomy of the 
parts is such that pus once formed burrovrs easily 
along the coarse muscular fibres and spreads oyer a 
large area because of the loose connectiye tissue so 
plentiful in this region. 

Pus ahyays goes along lines of least resistance 
and if this happens to be the mucous membrane of 
the bowel, as is usually the case, the abscess will open 

142 



ABSCESS. 143 

mto the bowel and later it will work its way to the 
outside and open spontaneously or be opened by 
the surgeon. In either case a complete fistula is the 
result which will recjuire operation later. 

Practically every fistula is the result of a previous 
abscess. Of course there are some few exceptions 
to this, as fistula might result from a surgical op- 
eration or a punctured wound, but these are accom- 
panied by pus formation so that the rule would hold 
good. 

Etiology. Any condition favoring the invasion of 
bacteria, such as a lowered state of health or a weak- 
ened vitality of the parts locally. A local lesion, 
such as ulceration, fissures, wounds, tears, or a dis- 
integrating pile tumor, or new growth, may open the 
way for infection and the formation of pus. Trau- 
matism either from Vv^thin or without may be the 
source of infection or start a small point of inflam- 
mation that may develop into an abscess. I have re- 
moved spicula of bone and pieces of wooden tooth- 
picks that had passed through the intestinal canal 
and caused the inflammation and pus formation. 

When the source of the disease originates in the 
rectum, the abscess almost invariably results in a 
complete fistula, Tubercle bacilli and other pyogenic 



144 RECTAL DISEASES. 

agents known to exist in the intestinal canal are the 
cause of suppuration in many instances. It has been 
proven beyond question that the tubercle bacilli may 
pass unharmed through the stomach and bowels until 
the rectal cavity is reached, where they may, by com- 
hip: in contact with an abrasion of some kind, start 
an abscess. The gastric juice will arrest their ac- 
tion but the alkaline intestinal fluids will at once re- 
store it. 

Other pus producing organisms that are common 
to the colon may cause the disease ; of these the most 
common are the bacillus coli communis, the strepto- 
coccus pyogenes, and the staphylo-coccus pyogenes. 
In addition to the above causes operating from with- 
in, there are many that produce their effect from 
without, as kicks, falls, blows, or traumatism of any 
kind, or from surgical operations ; the improper use 
of strong caustics in treating hemorrhoids, or by in- 
fection through lesions around the external margin 
of the anus. 

Tuttle thinks that a haematoma may form by the 
rupture of a small blood vessel caused by forcible 
divulsion of the sphincter muscle and infection take 
place, causing an abscess. 

In addition to the locah causes mentioned, the 



ABSCESS. 145 

constitutional condition of the patient has a good 
deal to do with the suppurative process. A person 
who is in perfect health has greater power of resist- 
ance than one whose tissues are weakened by disease. 
If the whole system is run down and the power of re- 
sistance is small, the ability to resist invasion by in- 
fectious germs is also small. 

There is another condition that has seemed to 
me to invite abscess formation in this region and that 
is the plethoric individual, the man who works little 
and eats much and whose tissues are constantly over- 
burdened with the products of digestion and tissue 
building elements. Any injury received by the per- 
son in this condition, although he may seem to be 
in good health, will cause the tissues to break down 
and suppurate. 

Varieties. It is a difficult matter to classify the 
different varieties as regards location but the fol- 
lowing seems to me to about meet all the require- 
ments : 

1. Subcutaneous or marginal. 

2. Ischio-rectal, 

3. Submucous, 

4. Pelvi-Rectal. 

In addition to the above we may have an abscess 



146 RECTAL DISEASES. 

in the prostate, urethra, or from disease of some 
organ or bone far from the region under discussion. 

Subcutaneous or Marginal Abscess. These occur 
around the margin of the anus and are due to the 
suppuration of a thrombotic hemorrhoid or to the 
infection of some one of the many glands or folHcles 
near the lower edge of the external sphincter muscle. 
An infected fissure may be the starting point, or 
any small tear or bruise which may allow infectious 
agents to enter the circulation. These abscesses are 
inclined to burrow away from the rectum rather 
than toward it and in many cases a fistula does 
not result; but as a rule fistula follows this form 
of the disease. 

Ischio-Rectal Abscess. This is what is generally 
known as the perirectal abscess and occurs in the 
ischio-rectal space on one or both sides of the anus. 
This space is filled with loose connective tissue and 
is poorly supplied with blood vessels, thus favoring 
sepsis and the formation of pus. It is entirely 
hemmed in with fascia so that considerable resist- 
ance is offered to the further extension of pus. For 
this reason when pus is formed on one side it often 
passes behind the rectum between the attachment of 
the levator ani and the 'ano-coccygeal ligament and 



ABSCESS. 



147 



gains access to the ischio-rectal space on the opposite 
side, thus forming what wih later become a complex 
or horse shoe fistula. 




Fig. 26. Diagrammatic representation of an ischio-rectal 
abscess. A, mucous membrane; B, submucous tissue; 
C, circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischio- 
rectal fossa; H, integument; I, tendinous insertion of 
logitudinal muscular fibres; J. deep. portion of external 
sphincter; K, superficial portion of external sphincter; 
L, interval between internal and external sphincter; 
M, internal sphincter; X, the abscess cavity. — Goodall 
and Miles. 

As the space immediately behind the rectum is 
the weak point or outlet for the flow of pus from the 



148 RECTAL DISEASES. 

fossa, so also, it is the weak point through which pus 
burrows into the cavity of the bowel, thus making 
the internal opening, while the two external open- 
ings, one in each ischio-rectal fossa, occur later, thus 
forming a typical horse shoe fistula. Occasionally 
pus may burrow anteriorly to the anus and form an 
anterior horse shoe fistula, but this is not common. 
In case it does do so it is more superficial than when 
it goes posteriorly and usually follows the raphe of 
the perineum and opens somewhere between the 
anus and scrotum or vagina or, in some cases, into 
the vagina. 

Submucous Abscess. This variety is found in the 
submucous tissue between the muscular layer and the 
mucous membrane. It is usually one one side only 
and has a tendency to burrow downward and open 
at the anal margin, or it may break in the bowel with 
the opening so high that it is found with difficulty. 
This is the form in which failure is often met with 
in fistula operations because of the fact that the ab- 
scess breaks both in the bowel and on the outside 
so far below its upper end or point of origin that 
when the tissues below the fistula openings are cut 
it leaves the main part of the abscess untouched and 
pus continues to form. This will be discussed furth- 
er under fistula. 



ABSCESS. 



149 



Pek'i-Recfal Abscess. This form of abscess or- 
iginates above the levator ani muscle and below the 
reflection of the peritoneum. They may extend 




Fig. 27. Submucous Abscess. A, mucous membrane; B, 
submucous tissue; C, circular muscular fibres; D, lon- 
gitudinal muscular fibres; E, pelvi-rectal space; P, 
levator ani; G, ischio-rectal fossa; H, abscess cavity; 
I, internal sphincter; J, interval between internal and 
external sphincter; K, external sphincter; L, deep por- 
tion of external sphincter; M, insertion of longitudinal 
muscular fibres; N, integument. — Goodsall and Miles. 

above the peritoneum. They are caused by some af- 
fection of the bladder, urethra, prostate, uterus, or 



150 RECTAL DISEASES. 

broad ligament. In women they are called pelvic 
abscesses and may be opened through the vagina. 

The connective tissue of the broad ligaments, 
meso-rectum, prostate and bladder are all continuous 
and if pus forms in almost any region of the pelvis, 
it naturally gravitates to the superior pelvi-rectal 
space. Injuries to the bowel wall on the inside above 
the sphincter muscle will cause this form of abscess. 
This may occur as the result of foreign bodies swal- 
lowed, as fish bones, etc., or it may be the result 
of ulceration or stricture. 

This form of abscess is chronic and will often 
wall itself off from the peritoneal cavity and work 
its way downward, sometimes forming a connection 
with the ischio-rectal fossa and giving the appear- 
ance of being limited to that cavity or it may burrow 
around the bowel and open in two or more places, 
giving the appearance of being a horse shoe fistula 
when it finally opens on the outside. 

Symptoms and Diagnosis. In the subcutaneous 
abscess the symptoms are much the same as those of 
a boil. There is in this the symptoms usually found 
where pus is forming, viz. : heat, redness, pain, and 
swelling. The pain in this variety is especially se- 
vere as it is just at the margin of the anus where it 



ABSCESS. 



iSi 



is to a certain extent in the grasp of the sphincters. 
There is a feehng of fullness and throbbing which is 
intensified by walking or sitting. 




Fig. 28. Diagramatic representation of a pelvi-rectal ab- 
scess. A, mucous membrane; B, submucous tissue: 
C, circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischio- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
the external sphincter; K, superficial portion of ex- 
ternal sphincter; L, interval between the internal and 
external sphincter; M, the internal sphincter; X, the 
abscess cavity. — Goodsall and Miles. 

On spreading the nates apart and at the same 
time requesting the patient to strain down, the swell- 



152 RECTAIv DISEASES. 

ing may be easily seen. It could scarcely be mistak- 
en for anything else unless it might be a thrombotic 
pile; but as an abscess is usually bright red, while the 
former is dark blue or black, the mistake is not like- 
ly. Even should such a mistake be made it would 
not matter as in either case the treatment would be 
by incision and in one case pus would be evacuated, 
while in the other a clot of blood would be turned 
out. 

In the ischio-rectal abscess there are much the 
same symptoms only they are intensified and there 
may be some constitutional symptoms, especially in 
the early stages. Should the abscess burst, especial- 
ly if it be in the bowel, all the symptoms are reheved 
and the patient thinks he is over with it for good; 
but in this he is mistaken, for it will refill several 
times and the symptoms will all be repeated before 
it finally settles down to be a fistula. 

As a rule there is no especial difficulty in making 
a diagnosis, as the symptoms of pain, heat, redness 
and swelling are too evident to be mistaken for any 
other condition. However, if seen early, before the 
pus has come near the surface, redness and swelling 
may be absent. The finger should always be intro- 
duced into the bowel as by this means much addi- 



ABSCESS. 153 

tional information may be obtained as to the extent 
of the suppuration and the hkehhood of its imme- 
diate rupture into the boweh Great caution should 
be exercised that the examining finger does not 
cause it to rupture, as this must if possible be 
avoided. 

In the submucor.s ^ ariety tlie chief symptom 
is pain during and followirg a bowel movement. 
This might be mistaken for the pain of a fissure, but 
it is not of the same character and is higher in the 
bowel than the latter. The i^ain of a fissure is an 
ache while the pain of a submucous abscess is throb- 
bing, sharp and lancinating. If rupture has taken 
place inside the bowel there will be a discharge of 
pus at stool and upon examination the finger will 
be found sm^eared with pus. 

The diagnosis of the pelvi-rectal abscess is more 
difficult than any of the other forms. Here the 
diagnostic symptoms of pus formation are not pres- 
ent, or at least not prominent. Because of the ab- 
scess being so high in the pelvis there is no local 
heat, redness or swelling and while tliere may be 
pain of an acute character, it is not localized to the 
rectal region, but is ill defined and extends through 
the back and down the thighs and seems to be more 



m 



RECTAL DISEASES. 



of a general pelvic cellulitis. There may be great 
constitutional disturbance with rigors, fever and dis- 
turbance of the functions of the bladder. 




Fig. 29. A Pelvi-rectal abscess which has invaded the 
ischio-rectai fossa. A, mucous membrane; B, sub- 
mucous tissue; C, circular muscular fibres; D, longitudi- 
nal muscular fibres; E, pelvi-rectal space; F, levator 
ani; G, ischio-rectai fossa; H. integument; I, tendinous 
insertion of longitudinal muscular fibres; J, deep por- 
tion of external sphincter; K, superficial portion of 
external sphincter; L, interval between internal and 
external sphincter; M, internal sphincter; X, abscess 
cavity; XX, its extension into the ischio-rectai fossa. — 
Goodsall and Miles. 

These abscesses are hard to diagnose and often 

mistaken for inflammations of the ovaries or broad 



Abscess. ±55 

ligaments. The disease is more chronic than the 
other forms and may last for weeks or even months 
before its true nature is ascertained and at times rup- 
ture may take place into the peritoneum or possibly 
into the bladder or vagina. 

Examination on the outside only reveals a ten- 
derness on deep pressure, but the finger in the rec- 
tum can generally outline a thick indurated mass 
high in the bowel wall. In men the urinary symp- 
toms are often so much more prominent than the 
rectal that the patient is treated by the passage of 
sounds and washing out the bladder and no attention 
is paid to the rectum. Exam 'nation of the blood to 
see whether or not there is an increase of white cor- 
puscles is always indicated if a diagnosis cannot be 
arrived at in other ways. Speculums and procto- 
scopes should not be used as they are liable to rupture 
the abscess inside the bowel. 

Treatment. An abscess in this region should be 
treated as it would in any other place, viz., by free 
incision and drainage. Most patients do not consult 
a physician until the abscess has ruptured or is about 
to do so and there is little opportunity to treat the 
case properly as might have been done earlier. If 
the pus has escaped before the patient has already 



156 



RECTAL DISEASES. 



consulted a doctor he will probably not do so at all 
as the tension has been relieved and he feels so much 
better that it does not seem necessary. 



X. 







I 



Fig. 



30. Showing T shaped opening in rectal abscess.- 
(Goodsall and Miles.) 



When seen early, if there is the least suspicion of 
pus, a free opening should be made and the necrosed 
tissue scraped out ; in this way healing will take place 



J 



ABSCESS. 157 

without the formation of a fistula. No possible 
harm can be done by the incision even if no pus is 
found and it may avoid serious suppuration. Should 
the patient absolutely refuse to allow this, he should 
be put to bed, a cathartic given and after it has acted, 
the bowels bound up with camphor and opium and 
the colon well cleansed with hot water, after which 
ice should be applied on the outside. In this way, the 
formation of pus may be avoided. 

If it is seen that suppuration is taking place in 
spite of this treatment there is nothing to do but 
apply hot compresses and wait for nature to bring 
the pus to the surface. I would advise that the 
physician insist on an early operation, as in this way 
many fistulas will be avoided. 

If the abscess is in the pelvi-rectal space the in- 
cision should be very free and the pus allowed to es- 
cape, after which it should be irrigated and packed 
firmly to avoid hemorrhage. If the wound has a 
tendency to close at the external opening, it should 
be incised at right angles to the first incision. 

In the sub-mucous abscess, if it has not already 
broken inside the bowel, an opening should be made 
on the outside and the pus allowed to escape. 

The after treatment consists in daily irrigation 
with weak bi-chloride, about 1-4000, and keeping 



1 58 RECTAL DISEASES. 

the parts open externally to get good drainage. The 
wound should not be packed very tight after the 
first dressing is applied. 



CHAPTER VIII 

FISTULA 

Definition — Variety of Fistulas — Etiology — Location — Symp 
toms and Diagnosis — Incomplete external Fistula — In 
complete internal Fistula — Complete Fistula — Treat- 
ment — Palliative treatment — Elastic Ligature — Injection 
of caustics — Incision — Aseptic measures — After treat- 
ment — Complications. 

A fistula is a pathological communication be- 
tween some cavity of the body and the outside. The 
ancients thought there was a pipe or reed leading 
from the inside to the outside because of the fact 
that, in rectal fistula, there was an escape of gas. 
Some fistulae, while they may be complete, are so 
tortuous that it is impossible for even gas to work 
to the outside. 

Fistulas are divided into complete and incomplete 
159 



i6o RECTAL DISEASES. 

and these are subdivided into blind internal or those 
having no opening on the outside, and blind external 
or those having no opening on the inside. The com- 
plete have both an internal and an external opening. 

In addition to the above, we have the complex or 
so-called horse shoe fistula where there are two or 
more external openings, but this is only a form of 
the complete variety. 

Btiology. Nearly all fistulas originate from an 
abscess and as these have been considered in a pre- 
vious chapter, but little more will be said on the sub- 
ject. The only exceptions are fistulas caused by 
punctured wounds. 

The question is often asked why fistulas do not 
heal more readily in this region when the external 
opening is in condition to allow good drainage. 
Probably the most plausible reason is because of con- 
stant reinfection and the passage through the sinus 
of the different pus producing germs of the bowel. 
This does not seem to account for the non closure 
of the external incomplete variety. 

I am convinced that but very few are actually 
without an internal opening into the bowel. Many 
times we cannot find this opening even though it ac- 
tually exists. Aside from this, however, the opening 



FISTULA. i6i 

on the outside is generally close enough to the anus 
to allow reinfection from this source. These fistu- 
lous tracks are seldom straight and while they seem 
to he well drained in fact they are not and may be 
in direct communication v;ith an old abscess cavity. 
In addition, tr.e constant movement of the parts, both 
in v.alking and the e^'acuation of the bowels pre- 
vents healing. 

Location. A fistula may occur in any part of 
the pelvis where tl^e formation of an abscess is pos- 
sible. The most common place for the internal 
opening is between the two sphincter muscles, but 
it may occur at any place around the anus or the 
perineum. It is not uncommon for more than one 
fistula to l^e present with no apparent connection. 

As spoken of under the head of abscess, when 
pus burrows from an ischio-rectal fossa behind the 
rectum to the other fossa it usually breaks through 
the posterior surface of the bovvcl and later breaks on 
the outside between the tuberosities of the ischium 
and the anus and a horse shoe fistula is the result. 

Symptoms and Diagnosis. The first thing that 
caused the patient to seek medical aid was the ab- 
scess that preceded the fistula, and this has been ful- 
ly considered, After the fistula has become estab- 



1 62 



RECTAL DISEASES. 



lished it will make itself manifest by the discharge 

of pus either on the surface or into the bowel ac- 
cording to Avhere the opening is 



Taking them in 




Fig. 31. Blind external fistula diagramatically represent- 
ed. A, mucous membrane; B, submucous tissue; C, 
circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischio- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
external sphincter; K, superficial portion of the ex- 
ternal sphincter; L, interval between internal and ex- 
ternal sphincter; M, the internal sphincter; X, main 
track of fistula. — (Goodsall and Miles.) 

separate order we will discuss the symptoms of each 
variety. 

Incomplete External Fistula, This does not open 



FISTULA. 163 

into the bowel, or at least no opening can be found. 
There is generally a discharge that seems to be most- 
ly serum with but little pus in it. Often the dis- 
charge is so small that it is not necessary to wear 
a cloth to catch it .and may even cease entirely and 
the external opening close, but it soon reopens. 
AMiile it is closed there is a feeling of weight and 
pain which is relieved when it breaks. 

The worst feature of this form of the disease 
is its effect on the skin as this, by being bathed in the 
serum and pus, soon becomes thickened and a pru- 
ritus may be established that will be hard to get rid 
of after the fistula is cured. 

Incomplete internal Fistula. This is the most dif- 
ficult form of the disease to diagnose. It is general- 
ly caused by a submucous abscess and the main thing 
complained of is pain at stool together with a dis- 
charge of pus. The patient will generally give a his- 
tory of having had the symptoms usually accom- 
panying the formation of pus as outlined under the 
heading of submucous abscess with a sudden dis- 
charge of pus and blood which relieved him greatly 
but the pus continues to discharge more or less at 
intervals although there is now but little pain. The 



164 



RECTAL DISEASES. 



disease may entirely disappear at intervals, but is 
sure to recur. 

The best way to make a diagnosis is with the 





M. 



\5^-. 



Fig. 3 2. Blind internal fistula diagramatically represent- 
ed. A, mucous membrane; B, submucous tissue; C, 
circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischio- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
the external sphincter; K, superficial portion of ex- 
ternal sphincter; L, interval between internal and ex- 
ternal sphincters; M, internal sphincter; X, the ab- 
scess and fistula. — (Goodsall and Miles.) 

fenestrated slide speculum. The internal opening 

pan usually be felt with the finger, but not in all 



FISTULA. 165 

cases. If this can be first located the speculum 
should be introduced and the slide withdrawn after 
having been placed over the supposed opening. By 
making pressure about the parts with the finger pus 
may be seen bubbling up into the bowel. By the use 
of a bent probe the extent of the track may be ascer- 
tained. Treatment should be carried out at the time 
the diagnosis is made as it can be done painlessly. 
This will be described later. 

Complete Fistula. There is but little difficulty as 
a rule in making a diagnosis of a Complete Fistula. 
The patient will often arrive at a diagnosis before 
he consults a physician. There will be a history of 
a previous abscess which has broken and discharged 
pus and may have refilled and broken several times 
until the discharge became constant. There is an 
escape of gas and fecal matter through the external 
opening and this with the pus and broken down tis- 
sue makes it very hard to keep the parts clean and a 
disagreeable odor is always present which is very un- 
pleasant to other people. 

The discharge is usually greater than in either of 
the other varieties ; its amount will show the quantity 
of tissue involved and the extent of burrowing that 
has taken place, as a short straight track will not 



1 66 



RECTAL DISEASES. 



discharge as much as a long one with many off- 
shoots or branches. The diagnosis is easily made as 
a rule, by introducing a probe into the external open- 




Fig. 33. A complete fistula diagramatically represented. 

A, mucous membrane; B, submucous tissue; C, cir- 
cular muscular fibres; D, longitudinal muscular fibres; 
E, pelvi-rectal space; F, levator ani; G, ischio-rectal 
fossa; H, integument; I, tendinous insertion of longi- 
tudinal muscular fibres; J, deep portion of external 
sphincter; K, superficial portion of the external sphinc- 
ter; L, interval between the internal and external 
sphincter; X, main track of fistula. — (Goodsall and 
Miles.) 

ing and feeling in the rectum with the finger for 
the other end. Sometimes the probe cannot be made 



FISTULA. 167 

to pass through the internal opening although one is 
known to be present. This is because the opening 
through the mucous membrane is higher than that 
through the other tissues owing to the fact that the 
original abscess broke through the mucous mem- 
brane at its highest point and later burrowed toward 
the sphincter and finally opened in the ischio-rectal 
fossa. 

If the track is very tortuous, as is often the case, 
it may be impossible to pass a probe through it. This 
is not important, however, as the diagnosis may be 
made in other ways. By palpation the course of 
the sinus may often be outlined running under the 
mucous membrane or skin. The injection of some 
colored fluid as milk or methylene blue will often 
reveal the internal opening. Some authors lay great 
stress on finding this opening, but I think its impor- 
tance over-estimated, as, if the treatment is by the 
knife an opening can be forced through and if the 
mucous membrane is examined and divided as high 
as it is undermined the result will be perfect. 

Treatment. The incomplete external is best 
treated by thoroughly dilating the external opening 
by freely incising it and scraping out all broken down 
tissue and then cauterizing it with pure carbolic acid 



1 68 



RECTAL DISEASES. 



or silver nitrate. In fact it is really converted into an 
open wound and allowed to heal by granulation. 

Some authors claim that there are no fistulas 
with an external opening but what has an internal 
one and that in case it cannot be found one should be 
p 



! /^ 



/ / 




.^ \ 



jd 



a c b 

Fig. 34. Fistula, a. Complete, b. External incomplete. 
c. Internal incomplete. 

made. I think, however, that there are many incom- 
plete external tracks that do not go near the mucous 
membrane of the bowel and to force an opening 
through all the intervening tissue would be foolish. 
Internal Incomplete. In case the internal open- 
ing is large enough to be felt with the finger, it 
should have a hooked probe inserted into it and 
drawn down until the point is seen to bulge the skin 
external to the sphincter muscle. At this place a free 



F^ISI^ULA. 169 

crucial incision is made, converting it into a complete 
fistula. 

It should now be v/ell cleaned from pus and blood 
and injected with the silver solution, as already di- 
rected, being careful to keep the external opening 
dilated for drainage. This will almost invariably 
cure these cases, and will not necessitate cutting the 
sphincter muscle. In case the internal opening can- 
not be felt, and there is simply a burrowing of pus 
under the membrane, it is not necessary to make an 
opening through the skin ; pick up the undermined 
tissue with a hooked probe, and incise it freely to 
the bottom of the sinus. 

In some cases the formation of the abscess begins 
above the place where the opening is located, having 
burrowed some distance before it breaks through. 
Should this occur, introduce a grooved director into 
the sinus and push it to the top of the undermined 
tissue. It is then forced through so that a bridge is 
left over the director that should be divided. It is 
well to be on one's guard in cutting the membrane 
high in the bowel, as a branch of the superior hemor- 
rhoidal artery might be severed, or even the main 
artery if the incision is carried too high. 

It should not be forgotten that this artery de- 



170 RECTAL DISEASES. 

scends along the posterior aspect of the rectum until 
within four inches of the external sphincter, or a full 
finger's length, and then divides into two branches 
that pass around the sides of the bowel, where they 
separate into many small ones. It is almost never 
necessary to go high enough to cut the main artery. 
Should it be feared, however, that this vessel or a 
branch might be included in the cut, make the incis- 
ion between two tightly tied ligatures, or better still, 
with the thermo-cautery. 

Complete Fistula. The treatment of complete 
fistula may be by one of the follow^ing methods : 

1. Incision. 

2. Injection of caustics. 

3. Elastic ligature. 

4. Palliative. 

Taking them in the reverse order given above I 
will discuss each separately. 

Palliative Treatment. At first thought there 
seems to be but little that can be done in the way of 
treatment except to cure the fistula, and further it 
might be said that there is no fistula but what ought 
to be cured. There are some patients far advanced 
w^ith pulmonary or other chronic disease upon whom 



i^ISTULA. 171 

operation is not indicated and they should be made 
as comfortable as possible. 

The warm sitz bath both morning and evening, 
pressing the track of the fistula, while in the bath, 
to remove as much pus as possible. A cloth wrung 
out of hot boracic acid water may be applied for an 
hour or two at a time after the bath and sterile gauze 
worn during the day. The bowels should move just 
before one of the baths is taken and a pint or more of 
boracic acid solution injected to wash out any re- 
maining fecal matter and cleanse the internal open- 
ing. 

The bow^els should not be allowed to get too 
loose, as fluid fecal matter will find its way into the 
fistulous track and aggravate the trouble. If the 
bowel contents are inclined to be hard and dry an 
ounce of oil injected previous to a movement will 
act favorably and be better than cathartics. 

Elastic Ligature. This treatment seems to me the 
poorest that could be adopted, but as it has been 
used for many years and still finds its way into 
text books, I will describe it briefly. 

The only thing in its favor is that it requires 
no cutting and the patient as a rule can go about 
his regular work to a certain extent. If there is 



I ^2 RECTAL DISEASES. 

any burrowing except the one straight track the 
method is Hkely to be a failure as these will not be 
included in the grasp of the ligature and pus pockets 
will form that will eventually work their way to 
the surface and cause new tracks. 

A small, round, soft rubber ligature is passed 
through the track by being threaded through the eye 
of a probe that has previously been passed and 
then drawn back carrying the ligature with it. As 
it is difficult to tie an elastic ligature, both ends 
are threaded through a perforated shot which is 
clamped upon them after they have been put upon 
the stretch. 

After the tissues have cut through so the liga- 
ture is loose it should again be drawn tight and an- 
other shot with a slit cut in it clamped on and the 
first one cut off. This is repeated until the ligature 
has cut its way out. This method in the majority 
of cases is exceedingly painful and many patients 
are confined to bed for a week or more. The whole 
area involved is a pus cavity that cannot be kept 
clean and many times it proves a failure. 

Injection of Caustics. Prepare the patient by the 
use of cathartic medicines, enemata, and restricted 
diet so that the colon will be as nearly empty as 



FISTULA. 



173 



possible. Syringe the fistulous track with a solution 
of peroxide of hydrogen and follow with plain wa- 




Fig. 35. Diagram atic representation of a submucous 
blind internal fistula resulting from a fissure. A, mu- 
cous membrane; B, submucous tissue; C, circular mus- 
cular fibres; D, longitudinal muscular fibres; E, pelvi- 
rectal space; F, levator ani; G, ischio-rectal fossa; H, 
integument; I, tendinous insertion of longitudinal mus- 
cular fibres; J, deep portion of external sphincter; K, 
superficial portion of external sphincter; L, interval 
between internal and external sphincter; M, internal 
sphincter; X, main track of fistula. — (Goodsall and 
Miles.) 

ter. After this is done anaesthetize the track with 
a 10 per cent solution of cocaine, Now fill a good- 



174 RECTAL DISEASES. 

sized rubber or glass syringe with a saturated solu- 
tion of silver nitrate. Put a rubber finger cot on 
the index finger and place it firmly over the internal 
opening of the fistula if it can be found. It can 
usually be easily located by careful search with the 
finger in the bowel. Put cosmoline on the skin to 
prevent it from being burned by the fluid that runs 
out. Introduce the syringe point firmly into the 
external opening, completely closing it, and with the 
finger covering the internal opening, force the in- 
tervening cavity full of the silver solution, holding it 
there for a short time. This will not only fill to its 
fullest extent, the main track, but also any branches 
that may be present. Remove the syringe, and with 
the finger, massage the fistula thoroughly to bring 
the medicine into contact with all parts. 

In case the internal opening cannot be located, 
force the solution in just the same, as, should it 
enter the bowel, no harm will be done. In some 
cases, especially if the internal opening cannot be 
found, it is better to use a hard rubber uterine syr- 
inge with a long nozzle with one or two openings 
that force the solution out at an angle of about forty- 
five degrees instead of from the point; this will ob- 
viate, to a large extent, its being forced into the 



FISTULA. 175 

bowel. This is much better than the small silver 
canula that is so often used, as the latter is apt to be 
forced into healthy tissue, where no track exists, 
while with the former this could hardly occur. 

i\s a matter of precaution, an ounce of sweet oil 
should be forced into the bowel to prevent any pos- 
sible damage to the mucous membrane that might 
result from the silver solution. Nothing should be 
put into the fistula after the silver solu^-ion has been 
injected. Unless the external opening is quite large, 
a crucial incision should be made to secure good 
drainage. 

The entire lining of the fistula will slough away 
in five or six days, and healthy granulations spring 
up to take its place. The external opening must be 
kept w^ell dilated to allow drainage, and a moist cor- 
rosive sublimate dressing applied for the first few 
days. If after two or three weeks the fistula is still 
present, the operation should be repeated. Often 
the first treatment will nearly close the sinus, and 
the second one is needed to complete the cure. 

Incision. By this is meant cutting the interven- 
ing tissue between the sinus and the skin and search- 
ing out and dividing any branches that may exist. 
There are several different procedures that may be 



1/6 RECTAL DISEASES. 

included under the name of incision, such as dissect- 
ing out the sinus intact and closing the wound with 

the hope of getting primary union, closing the in- 
ternal opening and cutting all tracks outside without 
cutting the sphincters, etc., but I will not describe 
these as the phys""cian who does but little of this 
\vo:k v.'culd scarcely make use of them. 

Pi'cl^araticn cf the raficnt. As careful aseptic 
measures should be carried out in these cases as 
ti'ough tliey vrere not already infected. It is of 
course impossible to get the parts in an aseptic con- 
dition, but this is no reason why it should not be 
as near in tliis condition as can be. If the caustic 
treatment l;as been used and proven a failure it has 
only put the parts in better condition and done no 
harm. 

About the same preliminary treatment should 
be carried out as described in the ligature operation 
for hemorrhoids. In addition to this the parts 
should be shaved and scrubbed with green soap and 
a moist bi-chloride dressing applied and left on over 
night. I think it well to give the intestinal antisep- 
tics and believe that beta-napthol comes nearer ren- 
dering the colon sterile than anything else. 

If there is not tog much cutting to be done the 



FISTULA. 177 

operation may be carried on under cocaine anaes- 
thesia, but if the tracks are deep and the openings 
numerous, chloroform or ether should be used. Hav- 
ing placed the patient on the table in the lithotomy 
position, if general anaesthesia is made use of the 
sphincters are thoroughly divulsed. If cocaine is 
used they are stretched as much as the patient can 
bear easily. 

A grooved director is now introduced into the 
external opening and allowed to find its way through 
the sinus into the bowel. If this is accomplished the 
finger is hooked over the upper end and it is pulled 
to the outside and a sharp bistoury run along the 
groove, cutting all the tissue upon it. If the muscle 
is included in the tissue cut, it shoald be divided 
square across and not diagonally. Search should 
now be made for any off-shoots from the main track 
and if any are found they should be divided. 

In old cases where there is much hard cartila- 
genous tissue, the so-called back cut should be made, 
that is, to draw the sharp edge of the knife through 
the back wall of every sinus found. It is well now 
to trim all over-lapping edges as they may inter- 
fere with the healing process. In case the director 
cannot be carried directly through the track because 



T 78 RECTAL DISEASES. 

'"t is too tortuous it should be carried in as far as it 
will go easily and the remainder of the way may be 
found by dissection without difficulty. This is real- 
ly the best way in any case as the tissues are not dis- 
torted by being forced out of their natural position. 
After all tracks have been divided, all overlapping 
edges trimmed and all hemorrhage of importance 
stopped, the wounds are tightly packed with sterile 




Fig. 36. Grooved director for operating on fistula, 
gauze, a large pad put on and held by a T bandage 
and the patient placed in bed. 

Horse Shoe Pistnla. As already stated this form 
of the disease is due to pus burrowing from one 
ischio-rectal fossa behind the rectum to the fossa on 
the opposite side. The internal opening is nearly 
always in the posterior wall of the bowel. The in- 
cision should be made V-shaped, cutting from the 
external opening on each side to the posterior com- 
missure behind and then cutting from there to the 
internal opening. This only necessitates cutting the 
sphincter muscle in one place. It matters not how 
many openings there may be on the outside, they 



FISTULA. 179 

can nearly always be traced to one opening through 
the bowel wall. 

After Treatment. A hypodermic of morphine 
should be given as soon as the patient is put in bed, 
the amount being regulated by the extent of the cut- 

Fig. 37. Horseshoe fistula. Lines of incision in operating 
ting. A pill of camphor and opium had best be 
given about twice daily for two days and the third 
night a couple of C. C. pills to be followed in the 
morning by liberal doses of salts. 

Twenty-four hours after the operation the ex- 
ternal dressings should be removed and fresh ones 
applied, but the packing should be left for at least 
forty-eight hours. When it is thought best, remove 
it by running over it hot bi-chloride solution 1-4000 
by which means it may be drawn out quite easily. 
The new dressing should be applied loosely and not 
packed in as the first was ; its only object being to 
keep the external edges apart so healing will take 
place from the bottom. The wound should be irri- 
gated once daily with sterile water, bi-chloride, or 



i8o 



RECTAL DISEASES. 



carbolic solutions. If the granulations become slug- 
gish they should be brushed with a 20 per cent solu- 
tion of silver nitrate or the wound packed with gauze 
wet with equal parts of balsam of peru and castor 
oil. 




Fig. 38. Complete fistula, showing how pus may burrow 
beneath the mucous membrane both below and above 
the opening into the bowel. 

Complications. Hemorrhage must be guarded 
against; any vessels that spurt should be grasped 

with artery forceps and tied. The packing should 
be put in very tightly and a good deal of pressure 
made on the pad with the bandage. After the re- 
action from the chloroform has taken place small 
vessels often relax and bleed freely. The dressings 
should be examined occasionally for several hours 



FISTULA. i8i 

to see that bleeding is not going on. If it is, the 
dressings should be removed and the bleeding point 
searched for and tied. If too high in the bowel 
to tie it may be grasped with forceps which can be 
left on for a few hours and the dressing reapplied 
around them. 

Another complication is an action of the bowels 
too soon after the operation. This is due to the fact 
that proper preparation was not carried out before 
the operation. If it occurs, the bowel should be at 
once irrigated with hot boracic acid solution and 
clean gauze packed in the wound if the first has come 
away or is soiled. 

Retention of urine often occurs and is due to 
the reflex action on the genito-urinary system. The 
same precaution should be taken as directed for 
hemorrhoids. In some cases the discharge will per- 
sist after it has apparently had time to heal. This 
is because some sinus has been overlooked and not 
divided. 

Incontinence of feces is the one complication that 
frightens the physician and often the patient from 
receiving the benefit of an operation. It is not as 
likely to occur as is generally believed as the in- 
ternal sphincter is seldom cut. If cut square across 



i82 RECTAL DISEASES. 

the fibres, the muscle will generally heal and be in 
as good condition as formerly. In my own prac- 
tice I have never known of a case of incontinence of 
any importance, but have had one or two where the 
cutting was very extensive that were slightly both- 
ered when the feces were liquid, but not enough to 
require the wearing of a pad. 



CHAPTER IX. 

ULCERATION 

Fissure — Irritable Ulcers — Diagnosis — Causes — Treatment — 
Palliative treatment — Incision — After treatment — Grad- 
ual Dilatation — Fissure in children — Divulsion — Rectal 
Ulcer — Classification of Rectal Ulcers — Treatment — 
Ulceration of the Sigmoid — Chief Symptoms — Differen- 
tial Diagnosis — Treatment — Irrigation of the Colon. 

IRRITABLE UIvCER OR I^ISSURE. 

The term fissure is generally used to designate 
the condition about to be described, but the proper 
name is irritable ulcer. It is spoken of as an anal 
fissure because it is never seen above the internal 
sphincter. Being located as they are where the ter- 
minal nerve filaments are numerous, they are very 
painful. This and their location distinguish them 
from the true rectal ulcer higher in the bowel, which 
is not very painful, in fact, often has no pain attend- 
ing it. 

The diagnosis is as a rule not hard. By separat- 
ing the folds of mucous membrane and skin, it may 

183 



i84 RECTAL DISEASES. 

be seen as an angry looking little sore that seems 
to cause the patient pain out of all proportion to its 
size. 

When a person comes complaining of a severe 
pain of a lancinating or throbbing character, com- 
ing on at or soon after stool, and continuing from 
one-half to several hours, and located at the anal 
margin, from which it seems to extend through the 
back pelvis, it is almost sure that he has a fissure or 
irritable ulcer. 

I know of no disease in which the patient can 
be given such prompt relief as this, and in no other, 
unless it be pruritis, is he so grateful. I have seen 
strong men cry like babies because of pain due to 
an insignificant looking sore that seemed to be in- 
capable of causing so much suffering. 

This disease is sometimes caused by polypoid 
growths, piles, internal incomplete fistula, or syph' 
ilis, and these should be searched for in all cases. 

TREATMENT. 

There are two plans of treatment that may be 
adopted. The first, or so-called palliative method, 
may be tried if thought best, and in case of failure, 
the second, or that of incision, will invariably effect 
a cure. If the palliative method is to be used, have 



i 



ULCERATION. 



tfie patient keep the bowels quite soft, being care- 
ful to not cause diarrhoea, and restrict his diet 
largely to fluids. Caution him to keep the parts 
clean by frequent bathing with cool water. Once 




Fig. 39. Typical Irritable ulcer or fissure, 
every two or three days for a while brush the ulcer 
with a twenty per cent solution of silver nitrate. 

The advice to use the solid stick is, in my opinion, 
bad, as it is not the intention to cauterize the ulcer, 
but to coat it over with a solution of albuminate 
of silver. If the parts are inclined to be dry and 
crack easily, the patient should be provided with 
some heavy ointment. One composed of the car- 
bonate of lead I dr., iodoform i dr., beef suet 4 dr., 
is the best. 



i86 RECTAL DISEASES. 

On the other hand, if too moist, a dry powder 
should be used. The following is excellent : Cam- 
phor 2 dr., carbolic acid 15 gtt., crete precip (Eng- 
lish) 2 oz., zinc oxid pulv. 2 dr., perfume q. s. Re- 
duce the camphor with alcohol and mix the other 
ingredients thoroughly and sift through bolting 
cloth of one hundred meshes to the inch. This, by 
the way, is a most valuable powder for chafing any- 
where, and I haA'e used it Avith great satisfaction as 
a toilet powder on babies in hot weather. 

Agnew of San Francisco speaks very highly of 
Salicylic Acid, but I have not had sufficient ex- 
perience with it to form an opinion as to its merits. 
The following formula is the one used by him : 

Acid salicylic gr. 15 

Morph. Sulph gr. i 

Ungt. bellad oz. i 

M. Sig. Apply twice daily. 

The old formula recommended by Cripps is very 
good to relieve the pain immediately following an 
action of the bowels : 

Ext. Conii dr. 2 

Olei Ricini dr. 3 

Ungt. Lanoline q. s. ad oz. 2 

Mix. 



ULCERATION. 187 

Since the introduction of orthoform, I have 
found nothing else necessary to reHeve the pain. It 
has the pecuHar power of reheving pain for several 
hours when applied to broken surfaces where nerve 
ends are exposed.. If put on an unbroken surface it 
is not so valuable. The best way to use it is the ap- 
plication of the dry powder to the fissure, but it may 
be put into an ointment and in this way made more 
convenient for the patient. The following is a con- 
venient form : 

Orthoform . . . gr. 15 

Ext. belladonna gr. i 

Ungt lanoline q. s. ft. ungt. 
Mix. 

This may be used through a hard rubber oint- 
ment pipe as shown on page 196 or simply applied 
with the finger. Should the pain extend well up 
into the rectum where it is difficult to reach, the 
above formula may be made into a suppository by 
substituting oil throbroma for lanoline. 

In case the suppositories cannot be introduced 
into the bowel because of the pain they cause, an 
ounce or two of warm starch water to which has 
been added from twenty to thirty drops of tr. opii 
may be carefully injected as recommended in proc- 



i88 RECTAL DISEASES. 

titis. It is seldom necessary, however, to apply any- 
thing above the sphincter muscle, as the fissure is 
very seldom above that point. 

The formulas given above are mainly for the 
relief of pain and do not have much curative effect 
and at the same time they are being used a more 
stimulating preparation should be applied. There 
is nothing that has given me greater satisfaction than 
ichthyol. It may be used pure by applying it once 
daily to the fissure or if preferred it can be made into 
an ointment or suppository. 

The application of pure ichthyol is not painful 
and may be used freely without cocaine anaesthesia. 
It should be applied once daily by the doctor and not 
left to ihe patient as he will not be likely to do it as 
it should be done. If kept up patiently for from 
one to two weeks a cure may be expected in a large 
proportion of cases. A few, however, will resist all 
efforts towards cure and some form of operative 
procedure will be required. 

OPKRATION BY INCISION. 

By this method some of the muscular fibres of 
the external sphincter are divided. It is, as a rule, 
not necessary to cut the internal sphincter, or even 
all of the external. The operation is done by in- 



ULCERATION. 189 

jecting under the ulcer a few drops of a solution of 
cocaine, and then drawing a sharp knife through its 
floor. This cures, not by the inflammation estab- 
lished, but by allowing the muscular fibres to rest 
until healing has taken place. 

This is proven by the fact that a cure results 
even though the incision is made through the muscle 
at some other place than the base of the ulcer ; also 
by the fact that in cases where two ulcers exist a 
single division will cure both of them. Should the 
ulcer extend too high to allow the upper end to be 
reached easily, a small speculum may be used, be- 
ing careful to direct the blades aw^ay from the af- 
fected side. After the incision has been made, place 
a pledget of cotton dipped in corrosive sublimate 
solution, one to two thousand, in the wound, and 
apply a pad and T-bandage. 

While this little operation is simple and easily 
done, it is one of the most satisfactory procedures 
in the whole range of rectal surgery, for the follow- 
ing reasons : It permanently cures the patient, there' 
is no possible danger of injury to the sphincter, caus- 
ing incontinence, neither is there the possibility of 
death from chloroform, as mig-ht occur where the 
sphincters are forcibly dilated, The pain is instantly 



I90 RECTAL DISEASES. 

relieved, and does not return. To be sure, there is 
some pain from the cut made, but it is trivial in 
comparison to that due to the fissure, and soon 
passes away. 

The after treatment consists in keeping the bow- 
els from moving for two or three days, after which 
a mild cathartic should be given, a small dose of cas- 
tor oil being as good as anything; when the desire 
for an evacuation is felt inject into the bowel an 
ounce of sweet oil. The patient should be kept in 
bed for a few days, and a mild boric acid dressing 
applied. Once daily a hot corrosive sublimate so- 
lution, one to three thousand, should be used to ir- 
rigate the parts. After the first week the patient 
may attend to his ordinary business, although the 
wound will not be entirel^^ healed for two or three 
weeks. 

GRADUAI, DURATION. 

This method may be used in some cases with 
little pain, and very fair results, especially in in- 
fants. This disease is found qxiite often in children, 
and a prominent New York sp^ialist in the diseases 
of children says that "wher, a child cries persistently, 
and if it is certain that it is not hungry or suffering 
from some digestive trouble, it is always well to 



ULCERATION. 



191 



examine for fissure." In such cases have the nurse 
oil her httle finger and carefuhy insert it into the 
bowel, going up a little higher each day. In case 
the pain is too severe, the fissure may be touched 
with cocaine solution. Some soothing ointment 
should also be used. 




Fig. 40. Dilators for gradual dilation of sphincter. 
In adults about the only thing that can be expect- 
ed in the way of cure is by the introduction of a 
small size dilator, and when it gets so it can be in- 
serted easily a larger one may be used; or the sur- 
geon may use a small speculum and carefully dilate 
the blades all that the patient will permit. This is 
too painful for the average patient, and very few of 
them will submit to more than one treatment of this 
kind. 



192 RECTAL DISEASES. 

DIVULSION. 

Forcible divulsion under chloroform as described 
on page no will cure every case and is to be pre- 
ferred where the milder methods above mentioned 

fail 

It cures by causing the muscle to be at rest from 
overdistention and paralysis thus giving the ulcer 
time to heal. 

RE^CTAI, ULCKR. 

The true rectal ulcer, or that form found above 



Fig 41. Cylindrical speculum for examining the higher 
parts of the rectum. 

the internal sphincter muscle, is not seen as often by 
the general practitioner as some would have us be- 
lieve. However, it is sometimes met, and is no 



ULCERATION. 193 

doubt often overlooked, and the patient treated for 
some other trouble. 

When a patient complains of diarrhoea that has 
extended over a considerable portion of time, and 
is not controlled by ordinary treatment, it is fair 
to presume that there is an ulceration of the rectum 
or sigmoid. Should the discharge be streaked with 
blood and mixed with mucus and shreds of mem- 
brane, the diagnosis will be almost certain. Pain is 
not a prominent symptom, and unless the ulcer is 
close to the sphincter, may be altogether absent. The 
diagnosis is best made with the tubular speculum of 
such length as may be necessary. If not too high 
in the bowel the proctoscope will reveal the lesion 
perfectly. Should it not do so, the sigmoidoscope 
may be introduced as far as possible, the obturator 
withdrawn, and a strong light thrown upon the tis- 
sue exposed ; by slowly withdrawing the instrument 
every portion of the surface of the mucous mem- 
brane from its upper end is plainly exposed to view. 
Should an ulcer be present, it may be easily recog- 
nized, as it will have the general appearance of an 
ulcer in any other part of the body. 

The disease is usually classified as follows : 
Traumatic, Syphilitic, Dysenteric, Tubercular, 
Catarrhal, Rodent, 



194 RECTAL DISEASES. 

tri:atment. 

This will depend largely upon the character of 
the disease. Many times it is impossible to tell just 
what kind of an ulcer we have to deal with, but as 
the general characteristics of all are about the same, 
the treatment will not vary a great deal. The trau- 
matic is probably the most common, and is due to 
an injury of some kind, as an impaction of feces, 




Fig. 42. A good sponge and cotton holder for rectal work, 
foreign substances lodged in the rectal pouch, or 
introduced from without, or from ulceration of a 
strangulated pile, etc. 

It is very important that the bowels be kept loose, 
and that they be well washed out after each move- 
ment with warm water. Two or three times a week 
an enema of water should be used containing about 
forty drops of nitric acid to the pint. This is es- 
pecially beneficial in the catarrhal form. Once or 
twice a week the ulcer should be exposed, and a solu- 
tion of silver nitrate, twenty grains to the ounce, ap- 
plied. In case the edges are indurated and shelving 



ULCERATION. 195 

the whole surface should be curetted, and pure nitric 
acid applied, followed at once by a strong solution of 
soda to neutralize the acid. The patient should re- 
main in bed and be put upon a liquid diet while this 
is being done. 

The bowels should be moved daily by injecting 
a pint of flaxseed solution, or an ounce of sweet oil. 
Of course, care should be exercised in regard to cur- 
etting or applying acid to too large a surface, as 
there will be some contraction, but in the majority of 
cases the surface involved is so small that there will 
'^e no danger. 

A\'hen large ulcerations exist, involving nearly 
the whole surface of the bowel, solutions of silver ni- 
trate, of from five to twenty grains to the ounce, 
should be used two or three times a week. After 
allowing this to remain in the bowxl for a few min- 
utes, it should be flushed out with a weak solution of 
sodium chloride and equal parts of water and fluid 
hydrastis (not fluid extract) should be used and 
retained if possible. 

In case there are varicose veins about the anus, 
and the mucous membrane seems lax and inclined to 
prolapse, Dist. Ext. of Hamamelis should be used in- 
stead of the hydrastis. If the ulceration is thought to 



196 RECTAL DISEASES. 

be syphilitic, treatment for this disease should be 
given and kept up for a long time. If tliis is not 
done the disease will return even though apparently 
cured. In syphilitic cases the ulcer should be dusted 
frequently with dry calomel. 

In the tubercular fGrm of the disease but little 
can be expected from local treatment. In most of 




Fig. 43. Pile pipe for e.pplyirg ointment to ulcers, 
these cases there is a local tendency toward a break- 
ing down of all the surrounding tissues. This is 
usually first seen by the physician as a tubercular 
abscess or fistula. Treatment should be mainly con- 
stitutional. 

The rodent ulcer is ^'cry closely allied to epithe- 
lioma, and some authors say that it is one of its va- 
rieties. It may be recognized by the fact that its 
edges end abruptly in healthy tissue; its surface is 
red and dry, it never entirely heals, and it is one of 
the most painful of all rectal affections. It may 
easily be distinguished from the irritable ulcer by its 



ULCERATION. 197 

general appearance, which as a rule is confined to 
mucous membrane, while the irritable ulcer is at 
the junction of the skin and mucous membrane, and 
involves both; but more especially by the constant 
pain. The treatment of rodent ulcer is so unsatis- 
factory that it is not worth while to attempt its cure 
except by surgical means under chloroform. 

UI.CERATION 01^ THE SIGMOID. 

Owing to the fact that this disease is too high 
to be easily reached from below, and too low to be 
easily found by palpation from above, it is often un- 
discovered. Diagnosis must be made mainly from 
subjective symptoms. 

The chief symptoms of inflammation of the sig- 
moid and colon are diarrhoea and abdominal pain, 
but pain is often not prominent except in acute cases. 
Diarrhoea, however, is always present, varying in 
degree according to the severity of the condition, 
and whether simple inflammation or ulceration is 
present. If there is simple acute or subacute inflam- 
mation, the stools contain no blood, but are very fre- 
c[uent and watery ; if ulceration be present, blood and 
shreds of membrane will be present. The stools 
often number fifteen to twenty-five a day, and in 
many cases the desire to empty the bowel is constant. 



198 RECTAL DISEASES. 

In addition to the above prominent symptoms 
there will be marked, constitutional changes, such as 
loss of flesh, sallowness of the skin, and general 
weakness. Ow4ng to the large amount of watery 
elements taken from the blood, there is considerable 
disturbance of the circulatory system, including pal- 
pitation, weak pulse and shortness of breath. 

The general weakness, and sometimes apparent 
lung trouble, lead the practitioner to suspect tuber- 
culosis, and, although the tubercle bacilli cannot be 
found in the sputum, the bowel symptoms would 
indicate intestinal tuberculosis. Owing to this diag- 
nosis many patients have died who might have been 
saved had a true knowledge of the trouble been ar- 
rived at. 

It is sometimes very difficult to make a differen- 
tial diagnosis between ulcerative colitis and tuber- 
culosis of the intestine, though in the latter there are 
often well marked lung lesions, which may readily be 
detected. The most marked evidences of intestinal 
tuberculosis not found in ulcerative colitis are irreg- 
ular fever, loss of flesh, sometimes constipation, and 
profuse sweating, especially at night. The main 
symptoms, however, are so nearly identical in both 
diseases that it is often difficult to distinguish be- 
tween them. 



ULCERATION. 199 

Dr. Mathews says : "The patient drifts from bad 
to worse, and after a while is a confirmed invalid. 
May it not be for w^ant of proper treatment? I am 
certain that many doubtful cases of diarrhoea or 
dysentery would find an explanation if the sigmoid 
were searched. Indeed, I have treated many cases 
and carried them to a full convalescence that had 
"gone the rounds" as chronic diarrhoea or dysen- 
tery. For all such patients I would suggest that the 
flexure be explored and treated, and many will 
clear up." 

I fully concur in the above statement, and feel 
sure that several cases under my care have been 
cured that would have died had the usual treatment 
by internal remedies been continued. In addition 
to the methods of diagnosis already mentioned, we 
can, by using the sigmoidoscope and electric light, 
arrive at an absolutely correct knowledge of the con- 
ditions present in most cases. 

Treatment consists mainly in giving the patient 
but little bulky food that will load the colon, and 
following about the same lines as directed for rectal 
ulceration. The mild astringents as Fl. Hydrastis, 
Pinus canadensis, weak solutions of silver nitrate, 
etc., should be used daily. Once a week, if there is 



200 RECTAL DISEASES. 

much blood discharged, a solution of silver nitrate, 
ten grains to the ounce, should be used. Hot water 
in large quantities has a stimulating effect upon the 
mucous membrane and should be used freely. This 
is done just preceding the injection of the medicine, 
and the latter is then injected and retained. 

In giving a high enema, the surgeon should use 
a Wales rectal bougie, but where the patient or 
nurse attends to this, I believe so stiff an instrument 
is dangerous in inexperienced hands, and might per- 
forate the bowel. Some patients can force water 
into the colon with an ordinary syringe, while with 
others it can scarcely be made to enter even the de- 
scending colon. 

There is considerable skill required in giving a 
high injection. As usually given, little, if any, more 
than the rectal pouch is filled, when the desire for 
an evacuation becomes so urgent that it cannot be 
retained, and of course, does no good. The patient 
should be placed on his side or back, as preferred, 
with the hips elevated, and a long rectal tube care- 
fully introduced so far as it will go easily. When an 
obstruction is reached, a little water forced gently 
through the tube will usually relieve it from the folds 
of membrane in which it is caught, and it can then 



tJLCEiRATiON. 261 

be pushed on until it passes the sigmoid, and the 
end Hes in the descending colon. 

Now if the fluid be allowed to flow very slowly to 
the upper part of the colon first, the rectal pouch 
will be filled last, and of course, all desire for an 
evacuation will be prevented until the large bowel 
is nearly or quite full. By removing the rectal tube 
from the attachment to the syringe or irrigator, the 
water can be allowed to flow out and a fresh supply 
introduced, thus filling and emptying the entire 
colon, so that the medicine used has been brought in 
contact with all the diseased membrane. 

A tube with an opening in the end, made for 
washing out the stomach, is better than an ordinary 
rectal tube, as the latter is too short. Any intelli- 
gent person can be taught to do this properly, and 
while it necessitates a great deal of work, the serious- 
ness of the disease, and the results that may be ex- 
pected, will fully repay the trouble. 

IRRIGATION O^ THE) COLON. 

There are certain conditions of the pelvic organs 
in which irrigation of the colon with hot sterile wa- 
ter or normal salt solution is of great benefit, not 
only to the diseased organs themselves, but to adja- 
cent organs. When it is remembered that the pelvic 



202 RECTAL DISEASES. 

contents are very closely related, both as to position 
and blood supply, and that their nerves are all from 
practically the same source, it is easy to appreciate 
how the application of moist heat to the interior of 
the colon would be beneficial to other organs. 

The effect locally is to wash out hardened fecal 
matter, dissolve and remove tenacious mucus, brok- 
en down epithelium and other catarrhal products, 
and stimulate the secreting glands as well as the 
muscular wall of the bowel, thus arousing its peris- 
taltic action. In addition, the kidneys are aroused 
to increased action, and as considerable water is 
absorbed through the blood vessels of the bowel, the 
amount of urine is increased, carrying with it much 
waste matter. 

The benefit to other pathologic conditions of the 
pelvic cavity is derived from the local heat in ad- 
dition to the general effect upon the circulation and 
kidneys, and this procedure is indicated in pelvic in- 
flammations of almost any character; also in col- 
lapse, shock, dysentery, yellow fever, typhoid fever, 
etc. In suspected cases of the latter disease I have 
by long-continued and repeated irrigations removed 
hardened fecal matter from the region of the cecum 
that had resisted the action of the most searching 



ULCERATION 2^3 

cathartics, and apparently had lain in that locality 
for weeks. x\fter their removal the typhoid symp- 
toms would at once clear up. In these cases there 
seems to be an accumulation of fecal matter which 
acts as a reservoir from which toxines are absorbed. 

I believe this to be true also in many other dis- 
eases, as cephalalgia, vertigo, indigestion, anaemia, 
chlorosis, and to a limited extent, in many others. 
One of our best clinicians has been quoted as say- 
ing that in his opinion "acute interstitial nephritis 
is often caused by the extra work tVirown upon the 
kidneys, due to a constantly overloaded colon." 

Sir Andrew Clark said that his reputation was 
made largely by his success in treating chlorosis, and 
this consisted mainly in keeping the colon free from 
toxines, and the judicious use of iron. This being- 
true, the value of flushing the colon with hot water 
is no doubt superior to the use of cathartics. In re- 
tention of urine, especially if due to spasmodic ac- 
tion, a ten-minute irrigation of the colon with wa- 
ter as hot as can be borne, will in many instances, 
start the flow. 

In acute inflammatory conditions of either the 
colon, rectum or adjacent parts the irrigation should 
be done two or three times a day, and continued fof 



204 RECTAL DISEASES. 

from fifteen to thirty minutes, using a double cur- 
rent rectal tube; by compressing the outflow tube 
the colon may be completely filled, in this way keep- 
ing from two to three pints of water in contact with 
the rectal wall all the time. 

If the water is very hot, it will not as a rule 
cause colicky pains, and if allowed to flow slowly 
at first, the desire for an evacuation, which usually 
occurs as soon as the rectal pouch is filled, will soon 




Fig. 44. Double current irrigating tube, 
pass away ; a long rectal tube is not necessary. The 
best position is on the back with the hips slightly 
elevated, and a fountain syringe with a fall of about 
four feet is to be preferred. 

In case there is no inflammatory condition, once 
or twice a week is often enough to use the water, 
and unless there is some well-defined reason for do- 
ing so, it should not be used at all. In ordinary 
constipation it should be considered as only an ad- 
junct to other measures, to be discontinued as soon 
as possible. 



ULCERATION 205 

The use of this treatment in health or as a con- 
stant practice in constipation, is to be deprecated, as 
it washes away the natural secretions and destroys 
the rectal nerves so that a bowel movement cannot 
be had without this unnatural stimulus. 



CHAPTER X. 

PROLAPSE OF THE RECTUM 

Falling of the bowel — Classifications — Incomplete — In Chil- 
dren — Causes — Symptoms and Diagnosis — Complete 
Prolapse — Causes — Diagnosis — Treatment for Partial 
Prolapse — Treatment for complete Prolapse — Tuttle's 
Operation. 

Used in its broadest sense, prolapse means a fall- 
ing or descent of the bowel so that it protrudes out- 
side the body. The disease is one that causes a great 
deal of suffering and in some of its forms is very 
hard to cure. In procidentia the bovrel may not ap- 
pear outside of the body in its early stages but will 
do so if left untreated. 

The disease is divided into two kinds, the com- 
plete and incomplete. The complete is that form 
in which all the coats of the bowel, in some cases 
even the peritoneum, are protruded, while in the in- 
complete only the mucous membrane comes out. The 
incomplete or partial form in its early stages is only 
an exaggerated protrusion of the normal mucous 

206 



PROLAPSE OF THE RECTUM. 207 

membrane as it turns outside the anus at defecation. 
Under certain conditions it becomes protruded far- 
ther and farther until it becomes pathological. 

As before stated a procidentia or intussusception 
is a doubling or invagination of the bowel within it- 
self and it may or may not protrude at the anal ori- 
fice, depending entirely upon at what period of its 
development it is met with. 

Incomplete or Partial Prolapse. This occurs near- 
ly always among children and generally has its or- 
igin in the summer diarrhoeas and is brought about 
by straining at stool. Anything that causes excess- 
ive straining such as stone in the bladder, phimosis, 
etc., may bring it about. In children the sacrum 
is very much less curved than in older people and 
the pressure is more nearly in a straight line than it 
is in adults, in whom it is against the curve of the 
sacrum. 

Paralysis of the nerves that supply the parts or 
any condition that takes away the natural support 
from below, as a relaxed sphincter muscle, may 
cause it. 

As a rule the prolapse comes on suddenly and 
the mother or nurse is greatly frightened ; again it 
may come on slowly and be several months in de- 



2o8 RECTAL DISEASES. . 

veloping. Some authors say that it never develops 
suddenly, but in this I am sure they are mistaken as 
I have seen several cases in my own practice that 
came without any previous symptoms. The first 
thing the mother recognized as being out of the 
normal was a mass two or three inches in length 
protruding from the anus. 

Symptoms and Diagnosis. As just stated, the 
first thing noticed is a protrusion of a mass from 
one to three incites long extending from the anus 
in^mediately following a severe fit of straining. Thi^ 
will not return of its own accord as the sphincter 
muscle is highly irritated and is inclined to spasmod- 
ically contract. The longer it remains out the more 
swollen and congested it becomes. 

It cannot well be mistaken for anything else un- 
less it might be hemorrhoids, but these come down 
in distinct tumors that are attached to one side of 
the bowel, while prolapse is a ring all around and 
does not come down much if any more in one place 
than another. There is one condition that is often 
seen in adults that is very confusing to the inex- 
perienced. These are cases where there are sev- 
eral large internal hemorrhoids that do not entirely 
protrude but force a ring of mucous membrane 
down in front of them. 



PROLAPSE OF THE RECTUM. 209 

A careless examination reveals nothing but the 
prolapsed bowel and the cause immediately above 
it is overlooked. By having the prolapse forced out 
and then asking the patient to strain down with con- 
siderable force they may be seen. They may easily 
be felt at this time by the examining finger. 

In case the prolapse comes on slowly, it is ac- 
companied by a lax sphincter which removes the 
support that holds it up and as this is essentially a 

disease of childhood the mother will observe the 
condition before it becomes serious and have such 

measures adopted as will check it. The differential 
diagnosis between this and the complete form will 
be discussed under the latter. 

Complete Prolapse. This occurs most often in 
adults and is a much more serious matter than the 
partial. All the coats of the bowel protrude, even 
the peritoneum in some cases, and occasionally coils 
of small intestine. It may be distinguished from 
the partial by its thick, solid feeling and also by the 
fact that the folds run around the mass, while in 
the partial they are longitudinal. The disease is not 
likely to be complicated with hemorrhoids. It comes 
on gradually and may be due to unusual force ap- 
plied from above or lack of support below, or both 
combined. 



2IO RECTAL DISEASES. 

Chronic constipation, especially when accom- 
panied with catarrh of the bowel, may cause a grad- 
ual thickening of the walls that may bring it about. 
When once the bowel has begun to protrude the 
constant irritation occasioned by its slipping out and 
in will cause hypertrophy of its walls that make it 
too large for the place it is supposed to occupy and 
for this reason nature is constantly trying to force 
it out. Polypoid growths of the sigmoid may drag 
the bowel down until it protrudes. 

There are three forms of complete prolapse rec- 
ognized by most authors, all of Avhich are really dif- 
ferent degrees of the same condition. The first is 
that just described or where all the coats of the 
bowel are forced out, beginning at the anus. 

The second is where the beginning of the descent 
is slightly above the anus and the third is where 
the beginning is a long distance above the anus or 
possibly in the sigmoid or colon. In each of the 
two latter forms there is a distinct sulcus into which 
the finger may be placed between the protruding 
part and the sphincter muscles. This is not true if 
the third form has not appeared at the outside, as 
is sometimes the case. While these cases are ex- 
tremely rare, I will quote the description given by 
Van Bueren, as it is very plain : 



PROLAPSE OF THE RECTUM. 211 

1st. ^'The most common, in which the greased 
finger, passed carefully around the base of the tu- 
mor, recognizes that its external surface is absolute- 
ly continuous with the membrane that lines the or- 
ifice of the anus without the existence of a sulcus. 
Here the bowel begins to slip out originally by its 
very lowest portion, and this had gradually formed 



1 



Fig. 45. Complete prolapse of the rectum. (Tuttle.) 
the outer layer of the protrusion, the gut, as it is 
forced down from above, passing within it. This 
form of complete prolapse follows simple protrusion 
of the mucous membrane, or partial prolapse when 
the latter has been neglected, 



2 1 2 RECTAL DISEASES. 

It results from a persistence of the causes which 
are keeping up the latter, and effecting its gradual 
increase by dragging upon the outer coat of the gut, 
when the submucous connective tissue will no longer 
yield. Such a tumor always contains more or less 
peritoneum, and it is important that you should never 
lose sight of this fact. The peritoneum, you will re- 
member, surrounds the rectum on all sides and ex- 
tends downward to an oblique line three inches and 
a half from the anus in front and scarce five behind. 
The peritoneal reflection at the base of a protrusion 
of this kind is, therefore, always larger in front. 

2nd. Where the finger can be inserted into a 
groove alongside the base of a tumor, so as to re- 
cognize a distinct sulcus, of more or less depth, at 
the bottom of which, if not too deep, the lining memi- 
brane of the gut may be felt as it is reflected from 
the base of the protruding tumor. In this case the 
rectum has begun to fold upon itself. In other 
words, to become invaginated, or, in the language of 
the day, 'telescoped,' the upper part of the bowel al- 
ways passing within the lower, at a point more or 
less distant from the anus, yet generally within reach 
of the finger. 

3rd. In this variety the finger can be inserted 



PROLAPSE OF THE RECTUM. 213 

through the anus alongside the protrudng tumor, 
but cannot reach any hue of reflection of the mucous 
membrane of the rectum upon the tumor, the latter, 
in fact, may not even as yet have protruded throueh 
the anus, but may be felt only as a polypoid mass, 
occupying the cavity of the rectum. Here invagina- 
tion has taken place higher up in the colon; has 
possibly commenced in the caecum or even ir ^'^^^ 
lower part of the ilium, which, sucked through the 
ileo cecal valve, has been carried with the cecum 
itself up the ascending colon, and, the connecting 
attachments gradually yielding, the invaginated 
mass has been propelled along the whole length of 
the colon and finally presents itself in the rectum, or 
may possibly extrude externally. This almost in- 
credible displacement of the parts has now been cer- 
tainly recognized in so many recorded cases, ex- 
amined after death, that it were inexcusible to fail 
tc recognize it during Ife." 

tre:atme:nt. 

Partial Prolapse. Often the first thing the physi- 
cial is called upon to do is to reduce the prolapse. If 
if; has been out a long time this may be a difficult 
thing to do. The parts become dry and swollen and 
if the patient is a child it will cry and strain until 



214 



RECTAL DISEASES. 



it seems impossible to get it back. Gravity helps 
more than anything else and the child should be as 
nearly inverted as possible; this will carry the con- 
tents of the abdomen and pelvis away from the rec- 
tum and the protruded mass will usually slip back in 
place. Gentle taxis should be made upon it while 




Fig. 46. Incomplete prolapse of the rectum. — (Tuttle.) 
this is being done, always remembering that the part 
that came out last should go back first. 

If the above measures fail, chloroform should be 
given which will relax the muscles and stop straining 
sufficiently to allow it to be reduced easily. In most 
cases there will be no further trouble if a little care 



PROLAPSE OF THE RECTUM. 215 

is used by the mother. The patient should be put in 
bed and kept there for some time and the buttocks 
drawn together with a broad strip of adhesive plas- 
ter. When it is necessary for the bowels to move 
the plaster may be cut through the center and later 
drawn together with laces. 

The child should not be allowed to sit on the 
commode but be made to use a bed pan. After the 
n:oA ement a little cold water should be injected into 
the bowel, to which has been added some alum, fluid 
hydrastis or otlier astringent. Of course if there 
is anything that is keeping up the irritation and 
strainirg, like phimosis, stone in the bladder, hem- 
orrhoids, etc., they should be attended to. 

If these palliative measures are not sufficient, 
more radical ones should be adopted. Allingham 
recommends the application of pure nitric acid. 
Some prominent men say it should never be used. 
In my hands it has been very satisfactory when used 
on children, but is not very satisfactory in adults. 
The object is to establish an inflammatory action 
that will cause the mucous coat to adhere to the 
tissues immediately beneath it. 

To do this the protruded mass is rendered in- 



2i6 RECTAL DISEASES. 

sensible to pain by the application of cocaine and 
four or five lines are made with acid in the long 
axis of the protrusion. After waiting a few min- 
utes a strong solution of soda is applied to neutral- 
ize the acid. The child should be put in bed and 
kept slightly under opiates to relieve pain and bind 
up the bowels. The diet should be very light and 
no bowel movement allowed for four or five days. 
About the same result may be obtained by applying 
the cautery at a dull red heat. This is done in the 
same way as the acid only the application is made 
before the prolapse is forced out. 

Tuttle recommends an injection at several points 
around the circumference of the anus of from three 
to five drops of modified Shuford's solution. After 
this is done a rubber drainage tube is inserted and 
the rectal ampula packed with gauze to hold the gut 
in position. This will allow the escape of gas and 
the bowels should be bound up for from seven to 
ten days. He advises that "a firm compress be put 
over the anus and the patient be kept more or less 
under the influence of opiates." "If carefully per- 
formed with proper antiseptic precautions, there is 

no danger of suppuration or sloughing in this meth- 
od, and the percentage of cures is fully equal to that 



PROLAPSE OE THE RECTUM. 217 

by the cauterizing methods mentioned above." 

The modified Shuford's solution referred to is 
prepared as follows and is recommended by the 
same author for the injection of hemorrhoids : 

Acid carbolic (Calverts) dr. 2 

Acid salicylic dr. ^ 

Sodii bi-borate dr. i 

Glycerine (sterile) p. s. ad oz. i 

M. 

Treatment of Complete Prolapse. This depends 
upon the conditions present. There are three main 
indications, viz. : to remove any exciting cause, as 
hemorrhoids, tumors, etc., to hold the bowel up 
from above and to improve the support below. In 
addition much good may be accomplished by consti- 
tutional treatment. 

Many of these cases are greatly debilitated from 
long illness or other causes and if the prolapse can 
be held in place until the general health is improved 
it will remain there. The methods described for 
partial prolapse will not be applicable in the com- 
plete form. If the mass is too large to remain in 
its place when reduced, and constantly acts as a 
foreign body, an operation may be done with the 
clamp and cautery the same as recommended for 



2i8 RECTAL DISEASES. 

hemorrhoids, only instead of removing tumors three 
or four sections of the bowel are clamped and cauter- 
ized, each being removed in the long axis of the 
bowel. 



Fig. 47. Complete prolapse originating above the internal 
sphincter. — ( Tuttle. ) 

The prolapse is then reduced and kept confined 
for several days.. This sets up an inflammatory 
action that unites the wliole intestinal surface to 
the surrounding parts and at the same time reduces 
the size of the rectum so that it ceases to be too large 
and no longer acts as a foreign body. 

If in addition to the operation just described. 



PROLAPSE OF THE RECTUM. 219 

the abdomen is opened and the bowel drawn up until 
it will come no further and then fastened in the ab- 
dominal wound the cure is likely to be perfect. 





Fig. 4 8. Complete prolapse which begins high in the 
rectum or sigmoid and does not appear outside. — 
(Tuttle.) 

Tuttle's operation. This is one of the most sat- 



^20 



RECTAL DISEASES. 



isfactory operations with which I am famihar and< 
Vv'ill result in a cure in most cases, provided not 
more than six inches of bowel protrude. 

Should a large amount of gut protrude, showing 




Fig. 4 9. Showing the first step in operation of suspend- 
ing prolapsed rectum to sacrum. 

that the attachments high in the pelvis are not per- 
forming their functions, this operation will not be 
successful, as it only fastens the lower end of the 
bowel and that portion left loose above this point 
vrill be forced down through the portion anchored 
to the sacrum producing an intussusception or in- 
\ agination. 



I 



PROLAPSE OF THE RECTUM. 221 

The following technique is followed in perform- 
ing this operation : The patient is prepared by get- 
ting the bowels as nearly empty as possible so that 




Pig. 50. The prolapsed bowel is now brought out through 
the incision previously made between the coccyx 
and anus and silkworm ligatures introduced. 

a movement need not be had for five or six days 
after the operation. The parts should be shaved 
and soap and bichloride poultices applied the night 
before. 

The best position is a rather exaggerated "Sims." 
with the hips well elevated. With the patient in 
position the gut is pulled down as far as it will go. 



222 



RECTAL DISEASES. 



A semicircular incision is now made midway be- 
tween the anus and the coccyx, going down to the 
descending bowel inside, but being careful not to 



cut through it. 




Fig. 51. With a long Pepsley's needle the ligatures are 
carried up through the incision and out on each side 
of the sacrum, each to correspond, as nearly as pos- 
sible to its position in the bowel wall. 
With the fingers the rectum is now separated 

from the coccyx and sacrum nearly if not quite to 
the top of the latter. The interior surface of the 
sacrum is now curetted to remove any fascia or fat 
that may be present. The prolapse is now reduced 
and pushed out of the opening previously made. 



PROLAPSE OF THE RECTUM. 223 

It is well to remove from the bowel thus drawn 
out any fatty matter that may be present and swab 
it with a strong mercuric solution (one to five hun- 
dred), or Lugol's solution of iodine, so that adhe- 
sions mav form. 




Pig 52. All are now tied over a gauze pad drawing the 
bowel up tightly against the anterior wall of the 
sacrum. The incision is closed and the kangaroo 
tendon inserted. 

Long silk worm gut or silver wire is now placed 
through the muscular coat of the posterior wall of 
the bowel embracing about one-third, if possible, of 
the bowel wall. Three or four of these are put in, 



224 RECTAL DISEASES. 

depending upon the length of the prolapse. After 
this has been done each ligature, beginning with the 
upper one, is threaded on a long handled Peasley's 
needle and introduced through the opening into the 
ano-rectal space, carried along the anterior surface 
of the sacrum as high as the denudation has been 
done and thrust through all the intervening tissues 
close to the sacral bones until it can be grasped by 
forceps, removed from the needle, and the latter 
withdrawn. 

The ligature on the opposite side and all the oth- 
ers are introduced in the same way. Each set is 
pushed through as close to the side of the sacral 
bones as possible and about one-half inch below 
the one above it. 

If any blood clots are present they should be 
wiped out and by making traction on the ligatures 
the prolapse is pulled up into the hollow of the sa- 
crum, a gauze pad is put on the outside and each 
set of ligatures tied over it. 

If the sphincters are m.uch relaxed a silver Avire 
or kangaroo tendon is run under the tissue around 
the anus and tied over the index finger. This nar- 
rows the anal outlet and acts as a support to hold 
the parts up. The bowels should not be allowed to 



PROLAPSE OF THE RECTUM. 225 

move for a week or more, when they should be in- 
duced to act by a boracic acid enema. A movement 
sitting up should not be allowed for three weeks. 
The incision made between the anus and the coccyx 
should be closed with catgut sutures. The silk- 
worm sutures should be left in about two weeks. 

There are several most excellent operations for 
the cure of complete prolapse, but as they come un- 
der the head of major surgery, the reader is referred 
to the larger textbooks for a description of the 
technique. 



CHAPTER XL 

NON-MALIGNANT GROWTH 

New Growth — Poh'pi — Neoplasmes — Size of Polypi — Usually- 
soft and pliable — Complications — Symptoms and Diag- 
nosis — Classification — Adenoma — Fibroma — Papilloma — 
Teratoma — Lipoma — Cystoma — Enchondroma — Angi- 
noma — Treatment. 

It is a well known fact that in all mucous cav- 
ities of the body there may be found new growths 
of a benign nature. These are especially liable to 
affect the lower end of the large intestine because of 
its more exposed position and greater chance of be- 
ing injured. These growths may be found in all 
parts of the intestinal canal, but are much more fre- 
quent in the rectum. According to Leichenstern 
they occur in about the following relative frequency 
in the intestinal canal : Duodenum, 2 ; ileum, 30 ; 
iliocecal valve, 2; cecum, 4; colon, 10; and rec- 
tum, 75. 

The general practitioner is likely to designate all 
of these growths as hemorrhoidal and even good sur- 

226 



NON-MALIGNANT GROWTH. 227 

geons often fail to diagnose them properly. When 
small they cause but few symptoms and unless they 
protrude may be entirely overlooked. Bodenhamer 
says, "The writer in a private practice of fifty-nine 
years, has treated ninety cases of rectal polypi, so 
called, in persons aged from three to seventy-five 
years; fifteen were in children under five years old, 
forty-five were adult females, and thirty were 
males." 

Some men prominent in the profession say that 
they ne^'er saw a case, but no doubt, like many oth- 
er diseases that were unknown in the past and are 
now considered new, better methods of diagnosis 
and more perfect attention to the technique of ex- 
amination enable us to recognize these cases where 
we would not have done so in the past. 

These new growths or neoplasms are generally 
called polypi, but the latter term includes all tumors 
that are attached by a pedicle that is smaller than 
the tumor itself, so any growth may be a polypus 
but any polypus is not necessarily a special variety 
of tumor. Many tumors are attached by a broad 
flat base and yet they go by the name of neoplasm or 
polypus and as these terms have in the past been re- 
garded as synonymous they will be so considered 



228 RECTAL DISEASES. 

here. As before stated, these tumors may be found 
in any part of the intestinal canal but are more fre- 
quent in the rectum and the most common point is 
the lower three inches of this cavity. 

They may occur singly or there may be two or 
more ; in rare instances the whole mucous membrane 
may be covered with small granular masses not larg- 
er than a mustard seed. They are generally pyri- 
form in shape and are attached by a slender pedicle, 
but they m.ay be round and have the appearance of 
earth worms, some of them measuring two or three 
inches in length. In size these growths do not as 
a rule get larger than a hen's egg, but there have 
been cases reported where the tumors were as large 
as a medium sized orange. 

The consistency and texture of these growths 
vary but they are usually soft and pliable, often 
feeling like mucous membrane. In appearance they 
are smooth in the early stages, but may become lob- 
ulated and roughened by the irritation of hard fecal 
matter. The constant tension to which they are 
subjected during a bowel movement tends to length- 
en the pedicle and in some cases they are actually 
forced out and the pedicle torn from its attachment, 
thus effecting a cure. 



NON-MALIGNANT GROWTH. 229 

They may be complicated with other diseases 

and in most of the cases that have come under my 
observation there have been hemorrhoids in addi- 
tion to the other tumors. The fibroid tumor is 
said to be the cause of fissures or irritable ulcers 
because of the effort on the part of nature to force 
them out, thus lacerating the mucous membrane. 

Symptoms and Diagnosis. In the early stages 
there are no symptoms, but v/hen the tumor becomes 
well enough developed to protrude, it at once makes 
itself manifest and is usually considered a hemor- 
rhoid. If located in the upper part of the rectal cav- 
ity, there may be a discharge of mucous and blood 
mixed, thus making it difficult to distinguish be- 
tween the malignant and non-malignant form of the 
growth. As the treatment would be the same in 
either case it does not matter especially as the micro- 
scope will settle the question after removal. 

There is not much pain unless the growth is 
quite large when there may be a feeling of weight in 
the pelvis with dull aching pains in the back and 
down the thighs. There will also be a good deal of 
tenesmus and a feeling that the bowel is not entirely 
emptied. 

Hemorrhage from the bowel in children is very 



^30 RECTAL DISEASES. 

often due to one of these growths and if not diag- 
nosed early, there may often be seen at the anal 
orifice a small bright red strawberry-like tumor that 
will appear at each movement of the bowels and be 
retracted out of sight in the meantime. In all doubt- 
ful cases the finger, speculum or proctoscope will 
generally clear up the diagnosis. 

Classification. These growths are usually classi- 
fied as follows : A brief description of each will be 
given. 

Adenoma. Lipoma. 

Fibroma. Cystoma. 

Papilloma. Enchondroma. 

Teratoma. Angioma. 

Adenoma. This is simply an exaggeration of the 
minute glands, follicles, or crypts of Lieberkuhn. 
They are generally found in young persons and may 
be single or multiple, never growing to be very large. 
They are attached by a short thick pedicle. They are 
very vascular which gives them a bright red color. 
As this growth is made up of an accumulation of the 
normal follicles of the bowel, it is at first simply a 
raised or thickened place in the bowel wall. As it 
continues to grow, the movement of the fecal mass 
against it constantly pushing it down so stretches the 



NON-MALIGNANT GROWTH. 231 



walls of the tumor that a pedicle is formed, in some 
cases long enough to allow the tumor to be forced 
outside. 

Fibroma. This is the tumor found most often in 







Fig, 53. Vertical section of simple adenoid. — (Kelsey.) 
the uterus. It is composed of fibrous tissue but may- 
have glandular and muscular elements. It is most 
often found in adults. It originates in the submu- 
cous connective tissue, is covered with smooth mu- 
cous membrane, generally has a distinct pedicle, and 



232 



RECTAL DISEASES. 



often attains a large size. In some cases the tumor 
remains in the bowel wall and has no pedicle. Tu- 
mors of this kind have been reported that were as 



^.^ 



.J 

-(Tuttle.) 



Fig. 54. Multiple adenoma of rectum. 

large as a fetal head. 

Papilloma. This is an outgrowth or enlargement 



NON-MALIGNANT GROWTH. 233 

of the papilla at the miico-cutaneous border of the 
rectum. They may be combined with the adenoma 
in which case we have the so-called adeno-papilloma. 
This growth appears as long slender processes and 
is usually seated on a wide base. 

Teratoma. This is one of the most infrequent of 
all these growths. It is a congenital tumor and is 
composed of some of the elementary cells of the 
body. Such tumors are not rare in other parts of the 
body and are most often found in connection with 
the ovaries. In the rectum, however, they are quite 
uncommon. These growths may contain hair, teeth, 
or in fact fragments of almost any of the tissues of 
the body. A case is on record where the surface of 
the tumor was covered with normal skin. 

Lipoma. This is the ordinary fatty tumor such 
as may be found in any part of the body. It is com- 
posed of a mass of fat cells held together by connect- 
ive tissue. It is more likely to spring from the upper 
part of the rectum and owing to its great elasticity 
the pedicle may be drawn out to a surprising length. 
It is said that the pedicle may contain a process of 
peritoneum which makes its removal somewhat 
dangerous. 

Cystoma. This is an exceedingly rare form of 



234 



RECTAL DISEASES. 



rectal neoplasm. The writer in quite an extensive 
practice has never seen a case. That such a growth 
might occur in this place is not to be doubted as they 
are possible in almost any part of the body. 




^■:>jL^rf' 



'V^ 



^^ 



"-^JL"'' 




:i"^v^ 



Fig. 55. Syphilitic condylomata. — (Kelsey.) 
Bnchondroma. This is a firm, tough growth, 
much resembling cartilage. These are not often 
found but cases have been reported by Van Bueren, 
Dolbeau and others. Kelsey says, ''Cartilaginous tu- 
mors of the rectum proper are of exceeding rarity, 



NON-MALIGNANT GROWTH. 235 

and when found they are generally the result of a 
secondary change in a tumor primarily glandular, 
and do not therefore present the well known charac- 
teristics of the typical enchondroma." 

Angioma. This is an erectile or vascular growth 
and is very much the same as a venous n?evus or 
macula materna. It consists of dilated veins and 




Pig. 56. Snare for polypus and other small growths, 
capillaries held together by submucous tissue. It has 
much the appearance of the capillary hemorrhoid but 
is more in the nature of a growth or tumor and does 
not bleed easily as the latter does. 

Treatment. All of these tumors may be removed 
by ligating the pedicle and cutting them off. Care 
must be exercised that the pedicle is not broken off 
in the effort to pull the tumor down so that the liga- 
ture may be placed. Should it be impossible to get 
the tumor out far enough to place a ligature around 
it, the snare may be used. This will cut through the 
pedicle and as a rule no hemorrhage will follow, or 



236 RECTAL DISEASfig. 

at least nor enough to be feared. If the operator 
thinks hemorrhage Hkely and cannot apply a ligature, 
the pedicle may be grasped with a pair of long curved 
forceps, the tumor cut off and the stump cauterized. 
In some instances the tumors have been forced 
out by the action of the sphincter muscle with such 
force that the pedicle was torn off and spontaneous 
cure would result. No after treatment is necessary 
except ordinary surgical cleanliness. 



CHAPTER XII. 

PROCTITIS AND SIGMOIDITIS 

Causes — Puncture of the Bowel — Acute Form — Chronic 
Form — Microscopical Examination — Treatment — The one 
Great Difficulty — Rest — Specific Proctitis — Irrigating the 
Descending Colon — Amebic Dysentery — The Diet. 

Acute and chronic inflammation of the different 
mucus membrances of the body are very common 
and manifest their presence in different ways accord- 
ing to the part affected, and whether acute or 
chronic. 

The causes that produce the disease in one place 

will do so in another. A sudden chilling of the body 
may cause a so-called cold in the head and sleeping 
on cold, damp ground may cause a proctitis, which, 
if left untreated, may become chronic and we have 
the chronic diarrhea so often found among elderly 
people, especially old soldiers. 

Then again we may have a specific inflammation 
of the rectal membrane generally due to indirect 

237 



238 RECTAL DISEASES. 

causes, as diphtheria, gonorrhea, etc., accidentally 
carried from some other part of the patient's body to 
the anal or rectal membrane by means of instru- 
ments, fingers or syringe nozzles, or by the discharge 
in females flowing over the parts. 

Among the causes in addition to those already 
mentioned, probably the most common one is trau- 
m.atism, either from within or without. From with- 
in, serious injury from substances swallowed, as 
pins, fish bones and other foreign substances. All 
such things w^ill pass through the stomach and small 
and large intestine without difficulty but lodge in 
the rectal pouch and set up an inflammatory process 
that results in a general proctitis or possibly an ab- 
scess. 

I haAX frequently taken such things from abscess 
cavities in this region. The disease may also be 
caused by the prolonged retention of hard dry, im- 
pacted, fecal matter, which is very irritating. Those 
causes which act from without are contusions and 
punctured wounds. It is not very uncommon to have 
tlie bowel wall punctured by the rough use of instru- 
ments or the finger in making an examination. In a 
recent issue of the Journal of the American Medical 
Association, Howard Kelley cites several cases 



PRACTITIS AND SIGMOIDITIS. 239 

where the wall of the bowel was punctured by the 
examining finger. This is more likely to occur in 
old people. 

In case such wounds are uncared for a proctitis 
and peri-proctitis would result that might be fatal. 
Kelly says such tears should be repaired by opening 
the abdomen and stitching from the peritoneal side. 
Owing to their being so low in the pelvis, it seems to 
me that this would be extremely difficult to do. In 
the chronic form of the disease, in addition to the 
rectal inflammation, we almost alwa3^s have an ex- 
tention to the sigmoid and often the whole descend- 
ing colon may be affected. 

In the acute form the pain is very great and is 
accompanied with tenesmus and considerable con- 
stitutional disturbance. There is a constant feeling 
that there is something more in the bowel, even after 
the patient has just left the commode, but this is due 
to the swollen mucous membrane. 

When the disease becomes chronic there is not 
much pain except on deep pressure over the sigmoid. 
The desire to go to the stool, while not constant as in 
the acute form, is still very troublesome and there 
may be from ten to twenty bowel movements dailv. 
This occurs more in the morning than any other part 
of the day and it is not uncommon to have four or 
five movements in rapid succession containing noth- 



240 RECTAL DISEASES. 

lug but bloody mucus or clear mucus resembling 
jelly, to be followed by a solid stool. The patient 
may then pass the rest of the day with but little dis- 
comfort. 

In its early stages it is difficult to diagnose this 
disease from cancer of the sigmoid but as the latter 
is essentially chronic while cancer runs its course in 
two or three years and as the sigmoiditis does not 
as a rule fall into the Doctor's hands until it has run 
for some tim(^ the diagnosis is not hard to make. 
A microscopical examination of the discharge should 
be made to diffe:rentiate between the common inflam- 
mations and amebic dysentery. As the ameba are 
not active in cold solution the examination should be 
made while the matter passed is still warm. 

In the chronic form of the disease the membrane 
of the sigmoid when examined through the sig- 
moidoscope has a very dark appearance and looks 
like fresh raw beef, and in some instances blood may 
be seen oozing from the bowel wall. 

Treatment. In the acute form this consists of 
rest to the inflamed part, a carefully selected diet and 
the use of mild, antiseptic, astringent solutions. 

The one great difficulty in treating proctitis is 
lack of drainage. The products of inflammation are 



PROCTITIS AND SIGMOIDITIS. 241 

retained behind a tight sphincter muscle and the 
greater the inflammation the more firmly does the 
muscle contact. This is true to so great an extent 
that often it is only with the greatest difficulty that 
a bowel movement may be had or an irrigator intro- 
duced. In such cases the patient had better be put 
under an anesthetic and the sphincter divulsed. 

In punctured wounds where the bowel wall is 
torn and pus has formed it may be necessary to cut 
the muscle posteriorly so that proper drainage may 
be obtained. 

There is no one thing that assists nature so much 
in bringing about a cure in a diseased organ as rest. 
For this reason, in acute cases the patient should be 
kept in bed and fed only highly concentrated food, 
such as will leave practically no residue to pass away. 
In fact if almost no food is given for a few days it 
will greatly assist in the cure. Another reason why 
the recumbent position should be insisted upon is that 
the rectum and sigmoid are drained by the middle 
and superior hemorrhoidal veins which have no 
valves and go direct to the liver through the portal 
system, and when the patient is standing the weight 
of this entire column of blood has to be lifted by the 
heart while, if he is lying down, gravity will greatly 



242 RECTAL DISEASES. 

assist in keeping the parts free from excessive con- 
gestion. 

In the acute form it is not common to have any 
extension to the sigmoid and for this reason any 
injection used need not be forced above the rectal 
pouch. A double current rectal irrigator should be 
used or if this is not at hand an ordinary soft rub- 
ber catheter may be introduced with the syringe 
nozzle for the return flow. By shutting off the out- 
flow tube the rectal pouch may be filled to its fullest 
capacity. 

The remedy that has given me the greatest sat- 
isfaction is Fl. Hydrastis in 25 per cent solution. 
Weak solutions of zinc and copper are useful, as are 
also the new preparations of silver, especially Ar- 
gyrol in from 5 to 10 per cent solution. Nitrate of 
silver should not be used in acute proctitis except in 
very weak solution. 

In order to control the constant desire to empty 
the bowel some local opiate is needed and nothing 
acts better than two or three ounces of starch water 
to which has been added from 10 to 20 drops of Tr. 
Opii. to be repeated as found necessary. 

Specific proctitis is not often seen and is general- 
ly due to gonorrhoea, The line of treatment should 



PROCTITIS AND SIGMOIDITIS. 243 

be the same as that followed in treating the disease 
in other localities. Irrigations with large hot per- 
manganate solution from 3 to 5 per cent in the 
early stages and later one or two ounces of Argyrol 
solution, injected into the bowel twice daily and re- 
tained. 

In the later stages of the disease more strongly 
astringent remedies should be used, and a good one 
is a mixture of Zinc Sulph., Bismuth Carbonate, Fl. 
Hydrastis, and water. 

In treating the chronic form of the disease we 
meet with a more difficult problem, as the sigmoid 
and often the descending colon are affected and ir- 
rigations must be forced beyond the rectal pouch. 
Most writers on this subject advise the use of the 
long rectal tube, but I have found from experience 
that it is exceedingly difficult to introduce this in- 
strument into the descending colon. I have used 
the utmost care in trying to do this and have con- 
gratulated myself that the tube Avas in almost its 
full length only to find that it was coiled in the 
rectum. 

My plan for irrigating the descending colon is 
as follows : Have the patient lie on his back with 
the hips well elevated. Have the water very hot and 



244 RECTAL DISEASES. 

the irrigator not more than two feet above the table. 
Use a short nozzle, not more than three inches long. 
Let the water run very slowly and if the patient says 
that he cannot hold it, stop the flow until the desire 
for an evacuation passes away and then start it again. 
It is only the first few ounces that cause a desire for 
an evacuation and as soon as the water begins to 
flow into the sigmoid this will not be felt, as a rule. 
If the sphincter is very lax, push the syringe 
nozzle through a small roller bandage and into the 
bowel and sufficient pressure can be rnade against 
the sphincter to prevent the discharge of the water. 
By using a double flow nozzle and compressing 
the outflow tube at intervals, the colon may be 
flushed with sterile water or salt solution after 
which such medicated solutions as may be thought 
best may be run into the bowel and some of it al- 
lowed to remain. 

This should not be done more than two or three 
times a week at first and later not more often than 
once a week. In case there is much blood in the 
^^'^c^^arge, a solution of silver nitrate seems to do 
— ore good than 'any other remedy. It should not 
^^ stronger than 1-2 of i per cent at first and may 
gradually b^ brought up to 2 or 3 per cent. It 



PROCTITIS AND SIGMOIDITIS. 245 

should not be used more often than once a week 
and if it causes much pain it may be followed by 
the normal salt solution, but this should never pre- 
cede the silver. Argyrol in 5 to 10 per cent solu- 
tion may be used with good results. 

In case amebic dysentery is present the solution 
should be used cold as the ameba cannot live in a 
low temperature. Tuttle claims to have cured sev- 
eral cases with ice water. A line of treatment which 
consists mainly in giving large doses of Epsom salts 
has proven very successful, mainly by keeping the 
colon clear of irritating material. The constant ca- 
thartic action of the drug is very depressing to the 
general health and really accomplishes no more than 
irrigation with salt solution. 

Great care should be taken with the diet and only 
the most concentrated and nutritious food given. 
Tea, coffee, and all alcoholic drinks should be pro- 
hibited. The treatment in the chronic form of the 
disease is necessarily tedious and requires consider- 
able time but if carried out faithfully will generally 
result in a cure. 

Should it be impossible to bring about a cure by 
the methods outlined a colostomy may be resorted to, 
and, by diverting the fecal current, give the bowxl 



246 RECTAL DISEASES. 

complete rest, or an opening may be made in the 
cecum and by means of a catheter the treatment 
may be carried on both from above and below as rec- 
ommended by Gibson. 



CHAPTER XIII. 

NON-MALIGNANT STRICTURE 

Stricture rare — Occur more often in women than men — 
Causes — Spasmodic Stricture — Pressure from without — 
Tubercular Stricture — Traumatic Stricture — Venereal 
Stricture — Symptoms and Diagnosis — Mahgnant Stric- 
ture — Treatment — Electrolysis— Instruments — Method of 
Procedure. 

Stricture is a comparatively rare disease and yet 
it occurs more often than it is supposed to because 
the physician in general practice does not recognize 
it and treats the patient for constipation, which is 
one of its symptoms. 

It occurs more often in women than men and is 
most common between the ages of twenty and fifty. 

There are two general classes of stricture, the 
congenital and acquired. The former will be con- 
sidered in the chapter on congenital malformations. 
I will discuss briefly some of the causes of stricture, 
as in this way a better understanding may be had of 
the treatment. 

247 



248 RECTAL DISEASES. 

Spasmodic Stricture. Whether it is possible for 
invohmtary muscular fibre to spasmodically contract 
so as to cause a narrowing of the calibre of the 
bowel has not been fully decided. I am of the 
opinion that this may occur as a result of some irri- 
tation such as an irritable ulcer or some reflex action 
from the genito-urinary organs such as might be 
caused by a stone in the bladder, but that it could 
occur without some such cause I do not believe. 

Mr. Harrison Cripps says that any irritation 
which causes a continual shortening of muscular 
fibre might in time cause the muscle to become per- 
manently shortened and thus cause a stricture. In 
urethral disease it is often found nearly impossible to 
pass a sound because of the spasmodic contraction in 
front of the instrument. 

If the canal is perfectly healthy this does not oc- 
cur as a rule. The same thing may take place in the 
bowel. A patient w^ith an irritable ulcer may find 
that when he undertakes to have a bowel movement 
the sphincter muscle will contract in spite of all that 
he can do and a temporary spasmodic stricture is the 
result. The above, it seems to me, is the true ex- 
planation of spasmodic stricture and w^hile it does 



STRICTURE. 249 

exist it is not a true stricture but only a temporary 
contraction clue to reflex irritation. 

Pressure From Without. This is not strictly 
speaking a stricture at all but is a narrowing of the 
bowel because of the pressure of some tumor or ad- 
hesive band on the outside. Probably the most com- 
mon cause of obstruction is a badly retroverted 
uterus. Any large tumor in the pelvis may cause 
sufficient pressure to produce a partial or complete 
closure of the bowel. A large pelvic abscess in fe- 
males may do the same thing and the bands and ad- 
hesions that may occur as a result of such abscess or 
from operations in the pelvis may produce the same 
condition of affairs. 

Tiihercidar Stricture. This is quite rare and is 
probably the result of a cocatricial contraction due to 
the healing of a tubercular ulceration. There is no 
way that I know of whereby sufficient tubercular 
deposit could be lodged in the rectal pouch to cause 
a stricture, because it is the tendency of this kind of 
deposit to break down rather than to build up and 
before a sufficient quantity could be lodged in the 
bowel wall to cause a stricture, it would break down 
and cause a tubercular or so-called cold abscess. 

Traumatic Stricture, This really includes the in- 



^50 



RECTAL DISEASES. 



flammatory form the disease and is the cause oi 
more strictures than any other single thing. That 
an injury of the lower end of the bowel could un- 
aided cause a stricture, I very much doubt, but when 
we consider that these injuries are followed by a 



1 '. ' " ". 




'"''"".• 


- ( 




" •-' 


'""'> 




* ', ^ 






. ': i: 










\ 








-4 • 


1 i 



Fig. 57. Annular stricture, 
long inflammatory process with much destruction of 
tissue and cicatricial contraction, it is easy to see how 
it may entirely occlude the calibre of the bowel. 
Any traumatism that sets up a proctitis may 



STRICTURE. 251 

cause stricture, among which may be mentioned 
surgical operations, impacted feces, the introduction 
of foreign bodies, as is sometimes done by the in- 
sane, pressure by the child's head in labor, enemas of 
too strong caustics, as the injection by mistake of 
pure carbolic acid or concentrated solutions of cor- 
rosive sublimate. Stricture due to the too free use 
of the cautery at the junction of the skin and mucous 
membrane is not uncommon and I have seen almost 
complete occlusion of the bowel from this cause. 
This is a stricture of the anus and not of the rectum. 

Venereal Stricture. This is in my opinion limited 
almost entirely to syphilis in its late stages. It is 
said to be caused by gonorrhoea and chancroids, but 
this is, I feel sure, a mistake. I do not wish to dis- 
cuss the matter here, but will only say that I never 
saw a case due to either of these causes in my own 
practice. 

As the years go by I am coming to believe more 
and more that our past opinions in regard to syph- 
ilis causing rectal stricture are wrong. That it does 
do so, there is no doubt, but not to the extent be- 
lieved by some. Allingham says that out of one 
hundred patients who had rectal stricture, a history 
of syphilis was traced in fifty-two or more than half. 



252 RECTAL DISEASES. 

While this may be true, I beheve that some of the 
fifty-two would have had stricture from other causes 
regardless of the syphilis. The fact that they had 
both at the same time was a mere coincidence. I be- 
lieve that to say twenty-five per cent of all stric- 
turs of the rectum are due to syphilis, is more near- 
ly correct. 

Stricture is caused by syphilis mainly by a gum- 
matous deposit in the submucous tissue and as a 
rule is deposited equally around the entire wall of 
the bowel. 

It may in this way be distinguished from cancer 
as the latter generally affects the bowel wall un- 
evenly and projects more in some places than oth- 
ers. Another diagnostic point is the fact that if left 
untreated it kills in from three to four years, while 
syphilis may last indefinitely. 

Symptoms and Diagnosis. Generally the first 
thing complained of is the ulceration which precedes 
the stricture but in case there has been no ulcera- 
tion, about the first thing complained of will be 
constipation alternating w^ith diarrhoea. The reason 
that these symptoms occur is that the fecal matter 
gathers above the strictured portion of the bowel 
and accumulates there until by its irritating action 



STRICTURE. 253 

it sets up a mild inflammation and an acute diarrhoea 
is the result. 

After this the patient goes along very nicely for 
awhile but gradually becoming more and more con- 
stipated and all the while increasing the amount of 
cathartic medicine that he takes until nature again 
starts the diarrhoea. These attacks are repeated at 
infrequent intervals until the stenosis becomes so 
great that he seeks surgical aid. 

In some cases, because of the irritation above the 
stricture, an abscess will form and burrow to the 
surface somewhere on the buttocks, leaving a com- 
plete fistula through which the feces are nearly all 
discharged. Patients have been known to live for a 
long time with no other opening than this fistulous 
track through which the contents of the bowel could 
be passed. 

On the other hand fistulous channels may form 
below the stricture. This is caused by the deposit of 
fibrous or gummatous matter in the bowel wall, 
which shuts off the blood supply to the parts below, 
resulting in local circumscribed death of tlie parts 
in small areas causing a breaking down of tissue 
and an abscess and fistula results. For reasons just 



254 RECTAL DISEASES. 

stated, when a patient is seen with a fistula the bow- 
el should always be examined for stricture. 

Probably seventy-five per cent of all strictures 
of the rectum are within reach of the finger and 
the diagnosis can easily be made in this way. If 
the well oiled finger encounters an obstruction w^hich 
it cannot easily pass, but having a small opning in 
the center, it is a stricture of some sort. The finger 
may be gently passed through the opening in many 
cases and in this way the extent of the strictured 
portion may be ascertained and whether the obstruc- 
tion is in the bowel wall or from some pressure on 
the outside. 

In case the stricture is beyond the reach of the 
finger, the proctoscope should be used. 

No one, regardless of how expert he is, should 
base a diagnosis of stricture of the rectum on the 
inability to pass a bougie. It has been proven be- 
yond question that a bougie will catch on the pro- 
montory of the sacrum or in the folds of mucous 
membrane in the hollow of the sacrum. The proc- 
toscope will in nearly every case reveal the exact 
location of the stricture unless it is above the sig- 
moid, in wdiich case an exploratory operation should 
be done. 



STRICTURE. 255 

If the stricture is not complete and can be seen 
plainly through the proctoscope, an olive tipped 
whalebone bougie may be carefully passed through 
the opening to ascertain its extent. Great care 
should be used to not puncture the bowel. 

In order to distinguish between benign and ma- 
lignant stricture, the following table taken from 
Ball is very interesting: 

NON-MALIGNANT STRICTURE. 

1st. Generally a disease of adult life. 

2nd. Essentially chronic and not implicating the 
system for a long time. 

3rd. The orifice of the stricture feels like a 
hard ridge in the tissues of the bowel. Polypoid 
growths, if present, are felt to be attached to the 
mucous membrane. 

4th. Ulceration of the mucous membrane may 
be present, but without any great induration of the 
edges. 

5th. The entire circumference of the bowel is 
constricted unless the stricture is valvular. 

6th. Pain, throughout the whole course, in di- 
rect proportion to the fecal obstruction and com- 
plained of only during defecation. 

7th, Glands not involved. 



256 RECTAL DISEASES. 

MALIGNANT STRICTURE. 

1st. Generally a disease of old age. 

2nd. Progress comparatively rapid and gen- 
eral cachexia soon produced. 

3rd. Masses of new growth are to be felt either 
as flat plates beneath the mucous membrane and the 
muscular tunic, or as distinct tumors encroaching 
on the lumen of the bowel. 

4th. Ulceration, when present, is evidently the 
result of the breaking down of the neoplasm; the 
edges are much thickened and infiltrated. 

5th. Generally one portion of the circumfer- 
ence is more obviously involved. 

6th. In the advanced stages pain is frequently 
referred to the sensory distribution of some of the 
branches of the sacral plexus, due to the direct im- 
plication of their trunks. 

7th. The sacral lymphatic glands can some- 
times be felt through the rectum, enlarged and hard. 

Treatment. Much may be done in the way of 
palliation, should an operation be refused or for 
any reason be thought not best. This consists main- 
ly in keeping the bowel contents in as near a fluid 
condition as possible. Strong cathartics should never 
be eiven, but laxatives are indicated, These should 



STRICTURE. 257 

be varied to meet the indications of the case. The 
different mineral waters, compound Hcorice powder, 
malt with cascara, etc., are all useful. Pure olive 
oil with about one-third glycerin added, while not 
greatly laxative, will, if given for some time, have 
a most excellent effect. 

Injections of water or oil do much good. The 
diet should be carefully regulated and the patient 
kept on milk, soup, soft boiled eggs and such things 
as leave but little residue to be passed away. 

In order to bring about a cure, more radical 
measures must be used. The easiest metliod for the 



Fig. 58. Wales rectal bougie, 

physician in general practice, is gradual dilation 
with Wales rubber bougies. I believe that it is near- 
ly if not quite impossible to bring about a complete 
cure in this way, but with persistence and with a 
short period of treatment, occasionally, all throug'h 
life many patients may be kept in pretty comfortable 
condition. This, combined with incision, is safe 
and will cure many cases, besides not requiring 
chloroform. Always use a bougie as large as will 



258 RECTAL DISEASES. 

pass without pain or requiring the use of force. No 
good can be accomplished by pushing a large instru- 
ment through a stricture and it is liable to cause a 
rupture of the bowel and peritonitis. 

Having found the instrument that will pass eas- 
ily the patient should be taught how to use it and 
instructed to pass it through the stricture at bed 
time and leave it there for an hour or more. At the 
end of a week a larger size may be tried and if it 
passes easily it should be used for a week when a 
still larger one may be used. Should the sphincter 
become irritated from the passing of the instrument 
so often, it will have to be stopped for a while. Still 
it does no good to begin this treatment unless it can 
be continued for a long time and with persistence 
and vigor. 

Some object to allowing the patient to pass the 
bougie, because they might do themselves an injury. 
I am satisfied that a patient of ordinary intelligence 
may be taught to do this without danger. It is near- 
ly impossible for them to come to the doctor's office 
every day and even if they did, he could not spare the 
necessary time. The stricture dilates much the same 
as a rubber band would do and for awhile will re- 
turn to its original size as soon as the instrument 



STRICTURE. 



=59 



is taken out, but if kept stretched more or less con- 
stantly for a long time, absorption will take place 
and it will be of larger size than formerly. 

This may be combined with incision or internal 




STRiCTIiKE 



Fig. 59. Tubular stricture, 
proctotomy if the stricture does not extend too high 
and involve too much of the bowel. This is done 
by dilating the sphincter through a speculum and 
cutting the stricture in one or more places down to 



26o RECTAL DISEASES. 

the bowel wall, being careful to not cut too deep. 
This accomplishes at once what gradual dilatation 
would require months to bring about. It should be 
followed by constant dilatation so the cut surface will 
not unite and leave the stricture in the same condition 
it was before. 

The worst objection to this method is the poor 
drainage and unless great care is used the rectal 
cavity will becom.e filled with pus and a proctitis and 
possibly an abscess will result. But if plenty of wa- 
ter with mild antiseptics are used, there need be 
no fear of this. 

In order to get good drainage, external proc- 
totomy is done in some cases. This consists in cut- 
ting all the tissues from the upper margin of the 
stricture to the coccyx. This makes a broad gutter- 
like wound that allows for drainage and free dis- 
charge of all bowel contents. It must fill in by gran- 
ulation which takes a long time, but the results are 
generally good. 

In case there is any reason to suspect syphilis 
large doses of iodide of potassium should be given 
and kept up for a long time, alternated with such 
pther anti-syphilitic remedies as may be thought 



STRICTURE. 261 

best. This will not remove the stricture but will 
prevent its further development. 

There is a remedy called thiosiamin, which is 
said to have the power of removing scar tissue from 
any portion of the body. Recently several cases of 
stricture of the pylorus, urethra, and rectum have 
been reported cured by this means. I have not had 
a chance to test it but shall do so at the first oppor- 
tunity. A fifteen per cent alcoholic solution used 
hypodermically is the best. Begin with about eight 
drops at a dose and gradually increase to sixteen. 
It is not best to use the injection more than twice a 
week. It need not be injected at the site of the stric- 
ture, but may be used on any part of the body. It 
wall probably do as well to give it by the mouth, but 
it is said to be somewhat irritating to the stomach. 

Treatment by Blectrolysis. As we come to know 
more about the use of electricity, the profession is 
learning that the negative galvanic current will cure 
non-malignant stricture if properly used, in well se- 
lected cases and combined with such other meas- 
ures as may be indicated. We are indebted to New- 
man for pioneer work along this line and the tech- 
nique taught by him is that followed by most op- 
erators. The following is from his writing as found 



262 RECTAL DISEASES. . 

in the International System of Electro-Therapeutics : 
Instruments. The armamentarium consists of a 
good galvanic battery with conducting cords, han- 
dles with sponge electrodes, a few binding screws, a 
set of rectal electrodes of different size and shape, 
and a milliamperemeter to measure the electric cur- 
rent. 

The electrodes have at one end a metal bulb, 
copper, brass, silver or nickel plated. The form is 
flat or egg-shaped ; they are made in sets of different 
sizes ; the length is from one- fourth inch to one and 
one-fourth inches, and the circum.ference from one 
and an eighth to three inches. 

The stem of the electrode, except at the extrem- 
ities, is insulated with hard or soft rubber; some 
are flexible, others stiff . If larger sizes are needed, 
a metallic bulb is used, similar in size and shape to 
vaginal electrodes, which are from three to five 
inches in circumference. Recently, VVaite and Bart- 
lett have made for the author an electrode for ex- 
amination and treatment which is superior to all 
former instruments. It consists of a bulb on a 
spiral stem, insulated with a rubber covering. The 
instrument will accommodate itself to the flexures 
and easily enter the colon, thereby increasing the 



STRICTURE. 263 

field of observation. Undue force is prevented; 
neither can the tube double or turn on itself. If 
made long enough it will enter the transverse colon. 

Modus Operandi. The patient may be placed in 
the Sims position, on the left side; but in the ma- 
jority of cases the I^ithotomy position, on the back 
is preferable, because in the examination and opera- 
tion the anatomical relations of the rectum and colon 
with the sigmoid flexure can be better appreciated. 
The galvanic battery is brought into action with the 
switch at zero. The sponge electrode, wet with 
warm water, and connected with the positive pole of 
the battery, is placed firmly in the palm of the pa- 
tient's hand, but in some cases may be pressed on the 
abdomen or thigh. 

The negative metal-electrode is lubricated with 
glycerin and inserted per anum to the seat of the 
stricture, and only then the electric current is slow- 
ly increased from zero, cell by cell, until the desired 
strength is reached, which is ascertained mainly by 
the sensation of the patient. 

The strength of the current allow^able varies 
from 5 to 15 or even 20 milliamperes, according to 
the seat of the stricture, the nature of the neoplasm, 
the size of the electrode, and the susceptibility of the 



264 RECTAL DISEASES. 

patient; the rule always being not to use a strong 
current if a weak one will accomplish the object. 

The treatment may last from five to fifteen min- 
utes. No force should be used ; the electrode should 
be kept steadily against the stricture, and only guid- 
ed; the electrolysis does the work of enlarging the 
calibre as the instrument passes the obstruction. At 
the end of the treatment the current is reduced slow- 
ly to zero, and not until then is the electrode to be 
removed. 

The treatment may be repeated in one or two 
weeks. According to circumstances and complica- 
tions of the disease, some modifications of the treat- 
ment may be called for, one of which is the use of 
needles in the mass of the stricture, instead of the 
metal bulb, at the negative pole. The smaller elec- 
trodes are very flexible and long, the object being 
that undue force is impossible while being used. 
Some operators use stronger currents, particularly 
if anaesthetics are used." 



CHAPTER XIV. 

WOUNDS AND OTHER INJURIES 

Common Wounds and Injuries — Causes — Fecal Impaction — 
Accidents — Danger of Injury — Treatment — Foreign 
bodies. 

The injuries most often met with here are in- 
cised, lacerated, punctured and contused wounds, 
both of the bowel itself and the surrounding parts. 
These may occur in various ways, but the most com- 
mon cause is contusions from falling on hard ob- 
jects as stones, the edge of seats, etc. Should the 
object fallen upon be sharp, there may be a punc- 
tured wound. There may also be an injury from 
foreign bodies too long retained or from pushing 
a bougie or other instrument through the bowel wall 
or the rough use of the finger in examining the 
parts. 

As stated in another place, Kelly reports five 
cases where the bowel wall was perforated in using 

265 



266 RECTAL DISEASES. 

too great force with the finger. This is more like- 
ly to occur in old people whose tissues are weak 
and easily torn. Several cases have been reported 
of puncture of the bowel wall, and injection into the 
peritoneal cavity of a pint or more of water or soap 
suds. 

There are many injuries to these parts in war, 
due to gun shot wounds, bayonet and sabre thrusts, 
etc. One of the most common causes of injury is 
from fecal impaction and foreign bodies. The for- 
mer is apt to cause tears and abrasions from strain- 
ing, and the use of instruments in its removal and 
the latter from the same cause with the added dan- 
ger of cuts from sharp edges or the breaking of 
glass, such as small bottles. 

Another class of wounds are those caused acci- 
dentally while operating on othei organs, as pros- 
trate or bladder. The bowel has been perforated by 
the old-fashioned stiff bougie in trying to dilate a 
stricture. As this instrument is now seldom used 
these injuries are not found. 

Wounds that perforate the bowel wall are ex- 
ceedingly serious if the opening is above the peri- 
toneum because it allows fecal matter to pass into 
the peritoneal cavity and peritonitis and death are 



WOUNDS AND INJURIES. 267 

the usual result. If the opening is below the reflec- 
tion of the peritoneum, it will not be so serious, but 
an abscess will result. There is apt to be infiltra- 
tion of the surrounding tissue, severe bleeding and 
extensive suppuration. 

The gravity of these injuries is the danger of 
peritonitis and the fact that there is such poor drain- 
age to allow the products of suppuration to escape. 

In case the injury is confined to the internal 
parts and nothing shows from the outside, the real 
gravity may not be appreciated and the delay occa- 
sioned may cause the loss of the patient's life. Se- 
vere hemorrhage may go on with no escape of blood 
on the outside as it will pass into the upper part of 
the bowel and fill the entire large intestine. This 
condition will soon bring on collapse and all the 
symptoms of shock. 

Examination by the finger will generally show 
the extent of the injury and in case it does not, an 
anaesthetic should be given and the sphincter dilated 
until all the parts can be easily seen. Preparation 
should be made at the same time to operate if nec- 
essary. 

trkatme:nt. 

In treating these wounds as before stated we 



268 RECTAL DISEASES. 

must make some provision for drainage. If there 
is hemorrhage going on which cannot be otherwise 
controlled the rectal cavity should be first thorough- 
ly washed out with hot water and then packed with 
gauze until the flow of blood stops. 

Of course if there is a tear in the bowel wall 
above the peritoneum the abdomen should be opened 
at once and the rupture closed from the peritoneal 
side. If this is not done the water used to wash 
out the bowel as well as the blood will at once pass 
into the peritoneal cavity. If the bowel contents 
have already escaped into the abdominal cavity, it 
should be wiped out with sterile gauze and then with 
alcohol. 

Nature will take care of a good deal of foreign 
matter and where no pus is present it is best to not 
flush the abdomen. In case the wound is below 
the peritoneum, the abdomen need not be opened, 
but if there is a rupture of any importance through 
the bowel wall the sphincter should be divulsed or 
if need be cut and the opening closed. It is much 
better to divide the muscle posteriorly and thus get 
the wound in good condition and w^here it can be 
seen and properly treated than to allow it to get into 
the foul condition that sometimes occurs. 

In dividing the muscle as suggested, we do not 



WOUNDS AND INJURIES. 269 

cut many of the muscular fibres, as they do not 
cross each other to a great extent, but pass directly 
back to their insertion into the coccyx. Nature will 
soon restore the divided parts to their former con- 
dition. Tlie wound should be flushed daily with 
mild antiseptic solutions and the patient kept quiet 
and not allowed to get out of bed until nearly all in- 
flammatory symptoms have passed away. 

In case a foreign body has lodged in the rectal 
cavity it often requires a great deal of ingenuity to 
remove it. As a rule, it is pushed in the easiest way 
and as soon as it passes the sphincter muscle the 
latter contracts behind it and every effort made to 
remove it only seems to push it farther in. Should it 
be glass, there is the added danger that it may break 
and lacerate the parts. If it is wood, it may be 
grasped with a pair of strong bone forceps and 
carefully removed. In some cases it may be of such 
a nature as to allow it to be cut to pieces and re- 
moved piece-meal. Rather than run the risk of mu- 
tilating the parts too much, the muscle had best be 
divided, which will allow the foreign body to be 
removed. 

In case it has passed into the sigmoid, an abdom- 
inal section should be done at once and it may be 



270 RECTAL DISEASES. 

removed through this opening or pushed back and 
removed without opening the bowel. 



CHAPTER XV. 

PRURITUS ANI OR ITCHING OF THE ANAL REGION 

Most intractable disease — Terminal Nerve Filaments — The 
only relief — Removing the Cause — Pruritis — Dr. Bull's 
statement — Intense Itching— Chronic Conditions — De- 
layed treatment — A prevailing cause — Unnatural Dis- 
charge of Moisture — The necessity of great care in 
Examinations — Causes of the Irritation — The Author's 
Conclusion — A small shallow Ulcer — Wallis' Conclusion — 
The Examination — The Discharge from small Ulcers — 
Symptoms — Treatment. 

This is the most intractable disease that the rectal 

surgeon is called upton to treat. It is often spoken 

of as a trivial matter, yet I have had patients who 

were almost physical wrecks, due to the loss of sleep, 

worry and nervous irritation. I believe that in its 

early stages it always has some well defined cause 

which, if searched for and removed, will cure the 

disease. A little later, however, the terminal nerve 

filaments become affected, and even though the 

cause be removed, or has long since passed away, the 

itching will still remain. 

The skin becomes thickened and parchment like 

271 



272 RECTAL DISEASES. 

and the nerA-e endings seem to be pressed upon and 
constantly irritated. In these cases nothing will 
give permanent relief except the destruction of this 
altered tissue and the formation of new skin. There 
are several ways of doing this, all differing in meth- 
ods, but aiming at the same end, of course if there is 
any cause that is keeping up the irritation, it should 
be removed. It would be very unwise to try to cure 
a pruritis due to eczema, pin-worms, fistula, hemor- 
rhoids, rectal catarrh, ulceration, etc., without first 
removing these. 

Dr. Bulls, writing in the British Medical Jour- 
nal, says, "At a recent meeting of the British ]\Ied- 
ical Association at Oxford, an interesting discus- 
sion took place, in the section on dermatology, on 
the causation and treatment of pruritis ani ; anyone 
reading that debate cannot fail to be impressed with 
the numerous numbers of distinct diseased condi- 
tions to which this annoying symptom was attrib- 
uted by the various speakers, and large as the num- 
ber of supposed causes assigned were, the various 
plans of treatment advocated Avere still greater." 

This disease is characterized by the most intense 
itching, which is worse when the patient gets into 
a warm bed. Patients have told me that pain would 



PRURITUS ANI 273 

be a relief and would be willingly borne in prefer- 
ence to the pruritus. Many patients do not consult 
the doctor until the disease has become chronic and 
it is then most difficult to tell what may have been 

the cause as the symptoms may remain, even after 
the cause has long since passed away. 

They will usually try all sorts of remedies before 

consulting a physician and when they finally do, the 
relief is often so transient and unsatisfactory that 

they drift from one to another with but little ben- 
efit from any treatment advised. They are likely to 
think that but little interest is taken in their case 
and go from bad to worse until by the time they 
get into the hands of a rectal specialist they are often 
in a serious condition. 

In my opinion the disease is caused in the great 
majority of instances by an unnatural discharge of 
moisture about the parts ; this may be brought about 
in various ways and by so many different conditions 
that a most careful search should be made to de- 
termine its source before any treatment is begun. 

As before stated, in chronic cases the cause may 
have disappeared, or if present, its removal may not 
end the trouble as the skin has become so thickened 
and thrown into folds that only its destruction or 



274 RECTAL DISEASES. 

removal will effect a cure. The irritation that 
causes the catarrhal discharge may be internal or 
external hemorrhoids, chronic proctitis, ulceration, 
fistulas, especially the small submucous variety with 
no external opening, pin-worms, hard dry feces 
which irritate the parts, the lodging of irritating mat- 
ter in the so-called rectal pockets, the growth of 
small polyps or in fact anything that will cause an 
irritation. 

Som,e of the patients who come for treatment are 
afflicted for the first time and the cause may be some 
error of diet, excessive smoking, or drinking, and 
but little treatment is necessary to effect its remov- 
al. After many years of study of this disease I have 
arrived at about the same conclusion as Wallis of 
London who attributes it to a small shallow ulcer 
just between the sphincters. He says : "In over 
ninety per cent of the cases so examined the shallow 
ulcer mentioned was found situated, usually between 
the two sphincters, more often in the posterior half 
than in the anterior, and generally in the dorsal mid- 
line; in some cases there is more than one ulcer, 
and, again in others there are various clefts which 
occasionally almost surround the bowel. This ul- 
per is not easy to recognize by the touch, and it re- 



PRURITUS ANI 275 

quires a certain amount of practice to appreciate its 
presence. In the first place, it must be remembered 
that it is only just within the anal margin, and al- 
ways below the internal sphincter. The smooth feel- 
ing of the healthy lining membrane will be recog- 
nized, but when the finger touches this abraded or 
ulcerated surface the smooth feeling disappears, and 
a slightly raised margin can be felt around the rough 
surface. There is sometimes pain, but more often 
none, associated with the examination. 

When the speculum is introduced, it must be re- 
membered that the tissues are pushed in, some little 
way by the instrument, and therefore the ulcer will 
appear higher up than it really is. If after its intro- 
duction the speculum is opened to its fullest extent, 
the inexperienced observer will probably not recog- 
nize the ulcer; but if the speculum is only slightly 
opened and, when possible, a careful view with a 
headlight is obtained, the ulcer can be clearly seen 
as a shallow oval, livid abrasion, differing markedly, 
and mainly in color from the normal mucous mem- 
brane. Here, then, is a definite lesion, in a so far 
indefinite disease, and it seems reasonable to believe 
that it might be the cause of the irritation." 

I have spoken of this little ulcer in former edi- 



2^e RECTAL DISEASEw^ 

tions of this work and further experience only con- 
firms my opinion of its importance. It should be 
understood, however, that it is not the ulcer itself 
that itches but it is the discharge flowing over the 
parts that causes the trouble. The skin becomes 
thickened and infiltrated, and loses its vitality. The 
nerve endings are compressed by the pressure made 
on them causing an irritation, and itching is the 
result. 

SYMPTOMS AND DIAGNOSIS. 

These are so evident that the patient will have 
arrived at a diagnosis before consulting the Doctor. 
He will probably say that he has "itching piles," as 
he is unable to recognize the cause of the trouble. 
His whole thought is how to get rid of the intol- 
.erable itching which is simply wearing his life out. 

Upon examination the first thing that will be 
noticed is that the skin about the anal margin is 
thrown into folds or ridges and that it looks unnat- 
urally sodden and dead ; also in most cases there will 
be seen an unusual amount of moisture coming from 
the bowel above. This roughness and moisture are 
often the lurking place for dirt and lint from the 
clothing which collects here, and irritates the parts : 
^ven those of cleanly habits are unable to avoid this. 



PRURITUS ANI zyj 

An eczema is generally present, often extending over 
a large area and the marks of finger nails may be 
seen showing the results of scratching. This chronic 
eczema is very hard to heal and does not respond to 
the ordinary remedies used for this disease. 

Careful search should be made for some of the 
conditions mentioned above in order to arrive at 
some conclusion as to the cause of the trouble. This 
should in all circumstances be removed, although, as 
before stated, it may not cure the disease. 

Treatment. The most important thing is to find 
the exciting cause and remove it, which in recent 
cases will effect a cure. If the skin has become thick- 
ened and rough, some method must be adopted to 
bring it back to as near its normal condition as pos- 
sible. In some cases this seems to be beyond the 
reach of drugs and only to be accomplished by the 
destruction or removal of the skin. A plan that has 
given me good results is the application of a ninety- 
five per cent solution of carbolic acid to the affected 
skin. I sometimes use a saturated solution of silver 
nitrate instead of the acid, as suggested by Adler. 
The epidermis peels off in a few days, leaving a 
somewhat tender surface that should be treated with 



278 RECTAL DISEASES. 

soothing ointments, such as the ointment of zinc 
oxide. 

After an interval of two or three weeks the acid 
should be put on again. This may have to be put 
on several times before "the skin becomes natural. 
Sometimes there are large warty ridges almost re- 
sembling piles. I never waste time with these, but 
simply cut them off and let the space fill in by gran- 
ulation. The intervening and all surrounding tis- 
sue is treated with the acid. 

This seems like rough treatment and so it is, but 
it should not be forgotten that we are dealing with a 
most stubborn disease, and decisive measures must 
be adopted to bring about a cure. Some patients 
object, but the majority are willing to submit to any- 
thing that promises relief. After all it is not so pain- 
ful, as the acid acts as a local anaesthetic, and while 
it burns somewhat, it is a comfort, as it stops the 
t-errible itching. 

The following case illustrates the benefits of 
this method of treatment. 

Mr. W., age forty, treasurer of an eastern Iowa 
county, and a man of more than ordinary intelli- 
gence, came to my office complaining of pruritus 
that was simply making life unbearable. The dis- 



PRURITUS ANI 2^<^ 

ease had troubled him for a long time, but was much 
worse at present than ever before. 

Examination showed the skin to be thick, parch- 
ment-like, and lifeless, with several heavy folds that 
radiated from the anal aperture. I explained to him 
that as he could not remain for treatment, anything 
that I did must necessarily be pretty severe ; also that 
it would have to be kept up at home for a long time. 
He replied that lie "did not care what I put on, as 
it would be a relief to what he was now suffering." 
I cut off all the redundant tissue and applied acid 
to the surrounding skin. I gave him the zinc oxide 
ointment to use until the soreness had left, and told 
him to have his wife apply the acid and to keep it up 
5LS long as seemed necessary. I also gave him the 
following injection : 

Dist. Ext. Hamamelis lo dr. 

Monsel's vSolution 2 dr. 

Phenol Sodique 6 dr. 

Glyceri;! 4 dr. 

Mix. Sig. Inject one-half teaspoonful in starch 
water at bedtime. 

He was warned against scratching, and told to 
forego all alcoholic drinks, excessive use of tobacco, 
rich meats, highly seasoned food, etc. He continued 



28o RECTAL DISEASES. 

this treatment for a long time and was rewarded 
with a complete cure. After six years there has been 
no return of the disease. 

In cases that are caused by a vegetable parasite 
I have made use of pure sulphurous acid with good 
results. It is generally used in solution, but I have 
found that it is better to use it full strength. It is 
quite painful, but one application is all that need be 
made, as it will destroy any living parasite that may 
be present. 

The application of very hot water followed by 
citrine ointment applied freely on gauze over which 
is tightly bound a pad that makes considerable pres- 
sure will often give relief so that the sufferer may 
obtain a good night's rest. 

In fact the citrine ointment is the best single 
agent with which I am familiar to bring about a 
permanent cure. When used persistently for a long 
time it will in many instances bring about permanent 
relief. 

It is said that French surgeons use a sharp cu- 
rette and scrape away all of the diseased skin, thus 
bringing about the same condition that we do by 
removing it surgically and bringing the edges to- 



PRURITUS ANl 281 

gether with sutures. The carboHc acid does the 
same thing only in a slower manner. 

Gelsey uses the white hot cautery, passing it 
lightly over all the affected parts. This, of course, 
is only another method of destroying the superficial 
layer of skin and allowing healthy tissue to take its 
place. It matters not what may have been the orig- 
inal cause of the disease or how long since this cause 
may have passed away, there comes a time when the 
terminal nerve filaments are bound down by the 
deposit of fibrous matter produced by the irritation 
•of scratching, and nothing short of its complete de- 
struction or removal will bring about a cure. 

As before stated, I believe that most of these 
cases originate from a catarrhal condition of the 
bowel and that if seen early enough, treatment di- 
rected to this condition, if carefully carried out, 
would cure the pruritus. Tuttle says, "Catarrhal 
disease of the rectum and anus are among the most 
frequent causes : whether it be the atrophic or the 
hypertrophic form, pruritus is one of the commonest 
symptoms. 

The dry, brittle condition of the muco-cutaneous 
membrane about the anus, described as a symptom 
of pruritus ani, is nothing more or less than a part 



282 RECTAL DIDSEASES. 

of the atrophic catarrh of the rectum and anus : and 
that moist, sodden, whitish condition seen in chronic 
cases is the result of the hypertrophic type." 

It is well known by all who do rectal surgery 
that after hemorrhoid operations or any condition 
where there is a wound that discharges pus as it 
heals, there is a constant pruritus on all the sur- 
rounding tissue, owing to its being constantly irri- 
tated by the discharge. 

Other causes that should be searched for, are 
constitutional diseases, especially diabetes, rheuma- 
tism, gout and all the conditions that go under the 
name of uricemia. There seems to be an irritant in 
the blood that causes cracks and fissures at all the 
mucocutaneous junctions and pruritus ani and vulvi 
which are very troublesome. 

These people are generally affected with eczema 
and the skin seems dry and scaly, specially about the 
scrotum on the breast and about the ears and hair. 

Certain errors of digestion as well as certain 
articles of food may start an attack of pruritus. 
Coffee has seemed to me to be more harmful than 
any other article of diet and will alone produce the 
disease in certain persons. All of these things should 
be searched for and, if found, given careful atten- 



PRURITUS ANI 283 

tion. I absolutely refuse to treat a person who is in 
the habit of drinking any form of alcohol. 

As a rule the treatment must be long and tedious 
and unless the patient will make every effort to as- 
sist in bringing about a cure I refuse to treat him. 

There are many formulas that that are used with 
more or less success, a few of which are here given. 
Tuttle speaks highly of the following : 

Ac. carbolici 2 dr. 

Ac. salicylici i dr. 

Glycerin i dr. 

Mix. Sig. Apply with camel's hair brush after 
bathing with hot water. 
Matthews recommends : 

Campho-phenique i dr. 

Glycerin i oz. 

Mix. Sig. Apply after using hot water and 
repeat frequently if necessary. 

In cases where there are fissure-like cracks at 
the junction of the skin and mucous membrane, 
Cripps recommends the following : 

Ext. conii I dr. 

Oi ricini i dr. 

Lanolini i dr. 

Mix. Sig. Apply frequently. 



284 RECTAL DISEASES. 

An ointment of chloroform as follows acts nicely 
in many cases : 

Chloroform i dr. 

Ungt. petrolati i oz. 

Mix. Six. Apply freqiiently. 

This must be put up in a wide topped bottle and 
kept tightly corked, as otherwise the chloroform will 
soon evaporate. 

Where the parts are too moist the treatment is 
often assisted by the use of powders that will absorb 
the moisture. Plain starch has given good results 
in many cases. Dry calomel many times is very use- 
ful. The following has given good results : 

Camphor 2 dr. 

Ac. corbol 15 gtt. 

Crete Precip. (Eng.) 2 oz. 

Zinc oxide pulv 2 dr. 

Perfume q. s 

Mix. Reduce the camphor with alcohol and mix 
the others through bolting cloth of one hundred 
meshes to the inch. 

I have operated under chloroform three times by 
removing a section of the skin for about an inch on 
each side of the anus and then undermining the sur- 
rounding skin and drawing it together to cover the 



PRURITUS ANI 285 

denuded surface and stitched it to the mucous mem- 
brane of the bowel. 

In two cases I secured good resuhs and the other 
was lost sight of. This procedure was suggested to 
me by my friend. Dr. Hamilton, of this city, and as 
a means of last resort I believe it to be very valuable. 
I intend to make further use of it as opportunity 
arises. 

Patients should always be told not to scratch the 
parts, although this warning is seldom heeded. If 
the itching is so severe as to interfere with sleep, 
have them use hot water, gradually increasing the 
temperature, until it is nearly scalding. In case this 
is not sufficient to give relief, an ointment of chloro- 
form, one dram, to one ounce of cosmoline, may be 
applied. A week solution of carbolic acid in water 
and glycerin will often give relief when all else fails. 
The following mixture is a most excellent one : 

Sodium hyposulphate i oz. 

Carbolic acid Y\ dr. 

Glycerin i oz. 

Aqua dest 3 oz. 

A/[is. Sig. Apply frequently on compresses. 
Also: 

Cocaine 2^ grr. 



t)' 



286 RECTAL DISEASES. 

Ex. rhatany 15 gr. 

Ext. hamamelis 7^ gr. 

Cosmoline 5 dr. 

Mix. Sig. Apply freely. 

Dr. Buckley recommends the following, and I 
can testify to its merits : 

Ungt. picis 3 dr. 

Ungt. belladon 2 dr. 

Tr. aconit rad Y^ dr. 

Zinc oxide i dr. 

Ungt. aqua rosa 3 dr. 

Mix. Sig. Apply freely. 

I have cured several patients by injecting cocaine 
under a small portion of the skin where it is thick- 
ened and then cauterizing it with the actual cautery. 
After healing has taken place another area is treated 
in the same way. This makes the parts quite sore 
but not more than is bearable, and most patients are 
willing to put up with it if it is likely to cure them. 

While the principal attention should bl paid to 
the skin in order to get relief from the itching, yet 
measures should be taken to cure the catarrh in the 
bowel above. I have the patient wash out the bowel 
with solutions of boracic acid and then inject a 
twenty-five per cent mixture of colored fluid hydras- 



PRURITUS ANI 287 

tis (not fluid extract). Other antiseptic astringent 
solutions may be used such as would be beneficial in 
catarrhal conditions in other parts of the body. 

Owing to the difficulty experienced in effecting 
a cure in some of the chronic cases that have come 
to me for treatment and being anxious to try any- 
thing that held out any hope of cure, I was led to 
try the Roentgen rays, and while my experience has 
not been great in the number of patients treated it 
has been so satisfactory that not only myself but my 
patients have been delighted with the result. 

This method is only useful in old chronic cases 
where the skin is eczematous and thickened. Just 
what the action is that brings about a cure I will not 
attempt to say, but that the eczema disappears and 
the skin returns to its normal condition or nearly so 
is beyond question. It is too soon to say positively 
how permanent the results are going to be, but I 
think from the appearance of the skin that there will 
be no return if the bowel above is put in a healthy 
condition. 

My technique is as follows — with a soft tube I 
give an exposure of ten minutes duration twice a 
week until I learn how the skin is going to stand it. 
If there is no irritation I sfive three treatments a 



288 RECTAL DISEASES 

week until a brown discoloration appears. All treat- 
ment is then stopped until this goes away, when 
treatment is resumed until it reappears. This is 
usually enough, but if possible I think it is well to 
give an occasional treatment after this as a matter of 
precaution. 

I know of no disease that will so tax the skill and 
ingenuity of the physician as this, and in all cases 
the patient should be made to understand that in or- 
der to be cured, he must be willing to do all in his 
power to aid the treatment. Many times the cure 
seems to be accomplished when a relapse will occur, 
which is very discouraging to both the patient and 
physician. 



CHAPTER XVI. 

CONGENITAL MALFORMATION 

Small per cent of Malformations — Necessity of examining 
the Child at Birth — Simple Narrowing of the Calibre of 
the Bowel — Diagnosis — Treatment — When the opening is 
closed by Membrane — Treatment — Absence of Anus — 
When the Rectum and Anus are Separated — Hopeless 
Cases — Artificial Anus. 

The phyiscian in general practice does not often 
meet with malformations of the lower end of the 
bowel ; many going through a long life-time of prac- 
tice without seeing a case. It is said that there is 
only about one case of malformation in four thou- 
sand five hundred thirty-eight births. While this is 
a small proportion, no one knows when the next one 
will happen or who will have charge of the obstetri- 
cal case in which it occurs. 

When a child is born it should be carefully ex- 
amined to see whether or not it is physically perfect. 
If not, measures should be adopted as soon as possi- 
ble to correct the malformation if it can be done with 

289 



290 RECTAL DISEASES. 

any reasonable hope of success. If there is not a 
fair chance of correcting the deformity so that it 
will leave the child in nearly a natural condition, it 
had better be let alone. 

I do not believe that under any conditions an 
artificial anus should be made except as a temporary 
expedient. The laity do not understand the gravity 
and seriousness of the matter or the terrible condi- 
tion in which the child must pass, not only its child- 
hood, but probably a long life. It had better be 
allowed to die in infancy, and, if the parents are 
sensible, and the matter is explained fully to them, 
they will agree that this is to be preferred. 

There are, however, a few conditions that may 
be remedied without much difficulty and the child 
left in a nearly natural condition. 

The first one is a simple narrowing of the natural 
calibre of the bowel without occlusion. This is near- 
ly always overlooked and no doubt many go through 
life without its being discovered unless there is con- 
siderable narrowing of the bowel. It generally oc- 
curs in the annular form and nature will often over- 
come a great deal of it. The only symptoms in most 
cases will be obstinate constipation. If the stricture 
is quite tight it will produce all the symptoms of in- 



MALFORMATION. 291 

testinal obstruction in other localities. It is not hard 
to diagnose, as the narrowing is always near the 
outside and may be felt by digital examination. 

The treatment consists in gradual dilation, if 
there is enough opening to allow this to be done. If 
not, do an internal or external proctotomy as di- 
rected in the chapter on stricture. 

The next form is where the opening is closed by 
a membrane stretched tightly across the anus. This 
is the simplest form of malformation and the easiest 
remedied and yet it will cause the death of the child 
unless attended to. Sometimes there is a very small 
opening at one side, sufficient to allow the discharge 
of meconium and liquid feces but when more solid 
substances attempt to pass, a complete obstruction 
occurs. The membrane will usually bulge outward 
so that the actual condition is easily recognized. The 
membrane should be cut in both directions across the 
center. The flaps left will shrivel up and disappear. 

The next form is where there is an entire absence 
of the anus and the rectum ends in a blind pouch 
somewhere in the pelvis. In this case there is no way 
to tell just where the lower end of the bowel actually 
is. It may be very nearly in its normal position and 



292 



RECTAL DISEASES. 



on the other hand, it may be a long way off, or it 
may end in the vagina or bladder. 

It is useless to cut blindly into the place where 
the rectum ought to be, hoping by mere chance to 




Fig. 60. Showing rectum ending in a blind pouch. (Kelsey). 

find it. The better way is to make an opening in the 
abdomen at the proper site for an artificial anus, 
bring up the sigmoid and make a small puncture in 
it through which a catheter or large bougie may be 
passed. By pushing this carefully down into the 
Jower portion of the sigmoid, if the lower end is any- 



MALFORMATION. 



293 



where near its proper place, it can be felt by pressure 
from the outside, and will serve as a guide upon 
which to cut and the bowel may be found and 
brought down and fastened in its proper place. 

After it has been found and loosened so it will 




Fig. 61. 



Rectum ending in a blind pouch; anus normal. 
(Kelsey). 



come down properly it should be secured by a liga- 
ture and then drawn back through the abdominal 
wound so the opening in the bowel through which 
the bougie was passed may be closed. After this is 
done the lower end is carefully drawn down and 



294 



RECTAL DISEASES. 



stitched in the perineum as near where the natural 
opening should be as possible. 

In case the bougie does not locate the lower end 
of the bowel in a place w^here it may be drawn down 
properly, an artificial anus may be made at the site 




Pig. 62. 



Showing rectum ending in the bladder. 
(Kelsey). 



of the original incision provided the parents desire 
that this be done after having the matter fully ex- 
plained to them. 

The next form is where the rectum ends some- 
where in the pelvis as just stated and the anus is 



MALFORMATION. 295 

normal but there is a distinct separation of the two 
ends. The septum is generally within easy reach of 
the finger and sometimes fluctuation may be felt in 
the lower end of the upper segment. There is no use 
of trying to operate on a case of this kind unless it is 
nearly certain that the two ends are close together. 
In this case the coccyx and possibly a portion of the 
sacrum must be removed and the two ends dissected 
out and united. When one considers the extreme 
smallness of the space in which he has to work, the 
difficulties to be overcome are at once recognized. 
There is only about an inch space between the tuber- 
osities of the ischium and the distance between the 
pubes and coccyx is not much greater. 

There are several other malformations that might 
be considered but those mentioned are the ones most 
often met and the rest will not be discussed in detail. 
I wish to say, however, that where the rectum ends 
in the bladder, vagina or urethra, I consider the case 
absolutely hopeless. 

The trocar should never be used under any cir- 
cumstances, as it is extremely dangerous. There is 
not one chance in a thousand that it will go into the 
right place and it may enter the bladder or so injure 
the peritoneum as to cause death. 



296 



RECTAL DISEASES. 



It is argxied by some that a colostomy should be 
done as a preliminary operation and when the child 
becomes older so that it can withstand the shock of 
more severe operations,' a search should be made in 
the perineum for the lower end of the bowel. This 




Fig 63. Rectum ending in Glans Penis. (Kelsey). 

would allow the use of the bougie or sound to assist 
in finding the termination of the lower end and give 
a definite point upon which to cut. There is good 
reasoning in this argument, as in addition to the in- 
creased strength of the patient it allows the attach- 



MALFORMATION. 297 

ment of the bowel in the perinum to heal without 
fecal matter passing over it and primary union may 
be expected. After this has occurred the artificial 
anus may be closed. 



CHAPTER XVII. 

RECTAL CANCER 

Most often seen in Adults between Thirty and Sixty Years of 
Age — Oftener in Males than Females — Symptoms — 
Diagnosis — Treatment — Diet — Four Considerations — 
The Importance of early Diagnosis. 

This disease is most often seen in adult life. It 
rarely occurs before thirty, and not often after sixty 
years of age, although cases are reported as occur- 
ring in children as young as six years. 

The malady affects males somewhat more often 
than females, and seems to be due in many instances 
to hereditary predisposition. 

The life of a person afflicted with rectal cancer 
is usually destroyed in three or four years from the 
beginning of the disease unless early operative in- 
terference is had. 

In a work of this kind it is not necessary to go 
298 



i 



RECTAL CANCfiR. 299 

into the classification, as the general features are so 
nearly identical in all that a person who is able to 
recognize one form will do so with the others. 

As about one-fourth of all cancers occur in the 
lower nine inches of the colon, and as early and com- 
plete excision offers the only hope of a radical cure, 
the necessity of recognizing the disease in its early 
stages is important. 

As to the symptoms and diagnosis, I cannot do 
better than to quote from Coley, in the Twentieth 
Century Practice. 

Symptoms. — "Uncomfortable feeling of weight 
and heaviness in the pelvis, with ill-defined feeling 
of annoyance after defecation. As the disease pro- 
gresses, the ill-defined symptoms assume a more 
definite character, the feeling of heaviness becomes 
one of distension, and the feeling of annoyance gives 
way to one of pain. The stools are more scanty and 
more frequent, and instead of well-formed move- 
ments porridge-like masses are passed covered with 
slime. Constipation alternates with diarrhea. 

Later on the calls to stool become more urgent, 
and the dejecta are composed mostly of mucus, pus, 
and a few scylbala, perhaps streaked with blood. A 
dozen or more times a day ineffectual efforts are 



300 RECTAL DISEASES. 

made to evacuate the bowels, temporary relief only 
being obtained by the passage of muco purulent mat- 
ter, the sensation of fullness, however, remaining. 
If the growth is located at the anal margin, the con- 
trol of the sphincter is lost early in the disease. 

"If the growth is located above the sphincter, loss 
of control comes on earlier, and seems to be due to 
the location of the growth. The nature of the pain 
depends on the location of the growth. If the 
sphincters are involved, the pain is intense, lancinat- 
ing in character, and radiating through the perine- 
um and down the thighs and legs. If the affection 
is seated in the upper part of the rectum or sigmoid, 
the pain is less intense, and severe only after the pas- 
sage of feces. 

"The cylindrical celled or glandular type begins 
by invasion of the submucosa, the early stages being 
unattended by any discharge, only with bulging of 
the mucosa into the lumen of the bowel does any 
ulceration occur. Emaciation and cachexia may ap- 
pear early. The disease steadily advances, invading 
the contiguous organs. The bladder, prostate, and 
urethra in the male, and the vagina in the female, 
also the uterus and ovaries. Ulceration often causes 
false passages. 

''Diagnosis. — The growth may often be seen at 



RECTAL CANCER. 301 

the verge of the anus ; it may be felt with the finger, 
or it may require various instruments to detect it. 
If the growth is at the margin of the anus, a hard, 
indurated mass with everted edges, possibly ulcer- 
ated, protruding above the surrounding surface. The 
anus is thickened and fissured here and there from 
loss of elasticity. The extent of the induration and 
the degree of constriction of the parts are in direct 
relation to the duration of the disease. 

"This condition may be confounded with chan- 
chroidal or tubercular disease, but the history and 
the presence of cartilaginous induration, and the 
ease with which a specimen may be obtained for 
microscopical examination will generally lead to a 
correct diagnosis. If the growth is located in the 
rectum, but within reach of the finger, and ulcera- 
tion has not occurred, great delicacy of touch is re- 
quired. Later, when ulceration has occurred, it is 
difficult to determine whether the disease is or is not 
malignant. This, however, is important, as treat- 
ment depends upon the diagnosis, and the disease 
may be cured at this stage. 

"Carcinomatous ulceration presents to the touch 
a well-marked area of induration with well-defined 
irregular margins. The induration extends diffusely 



302 RECTAL DISEASES. 

beyond the edges of the ulcer, gradually fading into 
the surrounding tissues. In other forms of ulcera- 
tion, the contour is regular, the induration slight, 
and the edges of the ulcer flexible. 

"If the ulceration has existed a number of years 
and been submitted to the action of escharotics, the 
character may be changed, but the chronic history 
will aid in the diagnosis. When the disease involves 
the whole circumference of the bowel and encroaches 
on the lumen of the surrounding tissues, the examin- 
ing finger easily maps out the difference between the 
healthy and diseased tissue. It recognizes the stric- 
ture, and by careful palpation, the mobility of the 
canal is determined. This feature should not be 
overlooked, as it permits the recognition of the in- 
volvement of surrounding organs. 

Should the stricture be too narrow to readily 
allow the introduction of the finger, force should 
never be employed in an effort to get beyond the 
strictured gut, as the diseased tissues are very friable 
and may be ruptured. Such an accident would result 
in peritonitis and death. The rapidity of the course 
of this disease renders diagnosis at this stage easy. 
Non-malignant ulceration usually gives a history of 
years of suffering and unattended by involvement 



RECTAL CANCER. 303 

of surrounding organs and general symptoms of 
cancer. When the disease is too low in the pelvis to 
be palpated through the abdomen, and too high to be 
reached by the finger, the various specula must be 
used." 

Treatment. — As operative interference will not 
be considered here, I will discuss briefly the pallia- 
tive treatment. 

The patient should in all cases be made to under- 
stand the gravity of the malady with which he is 
afflicted, and be allowed to choose whether he will 
accept the risk of an operation, or wait patiently for 
the end, with such relief as may be had from diet, 
local applications, etc. 

I think as a rule this disease should either be let 
alone or entirely removed. The more it is meddled 
with and treated, the faster it will progress. Still 
there are som^e conditions that may be benefited by 
treatment. One of these is where the cancerous 
mass is inclined to protrude and become raw and 
painful. Here the application of a paste of arsenite 
of copper will give great relief. Again, should the 
rectal cavity become occluded by a mass resembling 
a fungus growth, as it does sometimes in the en- 



304 RECTAL DISEASES. 

cephaloid variety, it may be curetted out and the 
canal cleared. 

In case pain is severe, the milder forms of opium, 
preferably codein, may be used. Morphine should 
be reserved for later use when the pain is often very 
great and large quantities are required. 

The diet should be very nutritious and composed 
of such things as leave but little residue to be passed 
off. In fact, the patient should be put on an invalid 
diet, composed of milk, eggs, soups, liquid pepto- 
noids, cod liver oil, etc. The latter is especially use- 
ful as it is a food and is very soothing to the mucous 
membrane of the bowel. I think no article of diet 
so nearly fills the indications as milk. Many persons 
think they cannot drink milk, but they can learn to 
like it, and by the addition of crackers or some of 
the many cereals now on the market, it will be nearly 
all the food needed. A moderate amount of fruit 
may be added for variety. 

The bowels should be moved daily without 
straining. Should there be difficulty in this regard, 
some of the mild alkaline waters may be taken. If 
necessary the patient should be instructed to pass a 
small soft rubber rectal tube and wash out the bowel 
daily with warm water. 

There are four things connfcte4 with this dis- 



RECTAL CANCER. 305 

ease that call for a colostomy and the formation of 
an artificial anus. 

First — Pain. Sometimes this is so great that 
the daily passage of fecal matter over the ulcerated 
surface is simply unbearable, and the bowel contents 
must be directed along another course. 

Second — Hemorrhage. The constant tearing 
open of exposed blood vessels will in some cases soon 
cause death if not stopped. It will usually cease 
when the artificial opening is made. 

Third — Diarrhea. This, in many cases of can- 
cer, is so severe that the patient will, if allowed, be 
on the commode most of the time. Colostomy is the 
only thing that will give relief. 

Fourth — Ohstruction. This may be so complete 
that a colostomy must be done to prevent immediate 
death. 

THE IMPORTANCE OE EARLY DIAGNOSIS IN CANCER 
OE THE RECTUM AND SIGMOID. 

There is a time in the life of all malignant 
growths when they are purely local and if removed 
thoroughly during this time recurrence will not take 
place. When these growths occur in the interior of 
the body where they are inaccessible to either sight 
or touch, mistakes in diagnosis and delay in operat- 



3o6 RECTAL DISEASES. 

ing are excusable, as the most expert diagnosticians 
are often unable to tell with certainty the nature of 
the trouble. When they affect organs or tissues at 
or near the different openings of the body, as the 
rectum, vagina, etc., no great degree of skill is re- 
quired to diagnose them, and it is entirely inexcus- 
able to allow them to progress beyond hope of re- 
covery before a diagnosis is made. 

My experience in treating rectal disease leads me 
to believe that something may be done to forestall or 
prevent cancer long before it has actually made its 
appearance. I do not put fnuch confidence in the 
theory that cancer is an inherited disease, neither do 
I believe that it is due to a germ, but I do believe that 
it is caused, at least in some cases, by prolonged 
traumatism, or irritation. This is especially notice- 
able in cancer of the cervix and pylorus, also in that 
due to irritation of the lower lip by the pipe or the 
so-called smoker's cancer. 

These localities are all subject to constant irrita- 
tion and should they become diseased from any 
cause, such as a prolonged ulceration, or small 
growths, or from the irritation of an old cicatrix, 
malignant disease may develop. I realize the fact 
that I cannot prove absolutely that this theory ig 



RECTAL CANCER. 307 

correct, neither can any one else prove that it is not 
true, or demonstrate beyond doubt any other cause 
for the disease. 

It is not at all uncommon to find cancer follow- 
ing an old laceration of the cervix; in fact most of 
the cases found here are in the cicatricial tissue of an 
old healed laceration. In his operative gynecology 
Kelley says in speaking of these cases, "A potent 
reason for operating on these cases is the remarkable 
frecjuency with which they are associated with can- 
cer." It is well known that ulcer of the stomach, 
especially if located near the pylorus where it is sub- 
ject to the constant irritaiton induced by the con- 
traction and dilatation of the muscular fibers may 
develop malignancy. 

As applied to rectal diseases I wish to quote 
briefly from other writers as to the liability of local 
irritation being the cause of carcinoma. Volkmann, 
Quenu, and Hartmann and Stierlin, as cjuoted by 
Tuttle, claim that 15 per cent, of carcinomas are pre- 
ceded by hemorrhoids. Gant says, ''In this connec- 
tion it is well to remember that the closest observers 
consider cicatrices, benign epithelial growths, ulcers, 
especially tubercular epithelium displaced from 
whatever cause and chronic inflammation, as predis- 



3o8 RECTAL DISEASES. 

posing causes of cancer." jMatthew says, "Chronic 
inflammatory products, cicatrices and benign epithel- 
ial tumors are favorable local conditions." I might 
quote many other authorities along the same line to 
proA'e my position, but believe the above sufficient. 
Granting, then, that cancer may be caused by 
local irritation, especially in localities near the dif- 
ferent openings of the body, it is important that 
these openings should be kept as free from disease 
and irritation as possible. 

In my study of rectal cancer I have found that 
almost without exception if questioned closely the 
patient will give a history of some rectal trouble that 
existed long before the actual beginning of the ma- 
lignant disease. This may have been in the nature 
of a fistula, especially one that has been operated on 
two or three times without success, or it may have 
been an ulceration that has involved considerable 
tissue, or to the constant irritation and chronic in- 
flammation due to the forcing out and in of old 
indurated hemorrhoids. 

While the sources of rectal irritation are very 
numerous the sigmoid does not suffer to a corre- 
sponding degree but to a less extent and in a differ- 
ent manner, and it is less frequently the seat of the 



RECTAL CANCER. 309 

disease than the rectum. It has one source of irrita- 
tion that the bowel, lower down, does not have, and 
this is chronic inflammation. This is due to the fact 
that the sigmoid is the receptacle for fecal matter, 
while the rectal pouch is, or ought to be, empty most 
of the time. 

During the winter of 1904-05, within a period of 
about four months, I had seven cases of rectal can- 
cer, all but two of which were so far advanced that 
hope of relief from operative precedures was out of 
the question. These persons all had histories of 
some rectal trouble dating back several years, show- 
ing that the disease was originally some less formid- 
able malady which might have bene cured, with, 
possibly, the prevention of the cancer. I do not wish 
to be understood as saying that hemorrhoids, fistula, 
etc., may turn into cancer, but that the traumatism 
and irritation which they produce may put the tissue 
in such shape that malignant disease may develop. 

A human being, from a mechanical point of view, 
is much the same as a machine; the latter will, if 
allowed to get out of order, or broken, soon go to 
pieces if not repaired, because of other breaks caused 
by the failure to mend the first one ; just in the same 
way the human machine is weakened, because cer- 



310 RECTAL DISEASES. 

tain abnormal conditions that are readily curable 
are neglected. Should the disease be one that in- 
volved great risk of life or where the result was un- 
certain, there would be some excuse for delay, but 
nearly all of these iinder consideration are not espe- 
cially difficult to diagnose and cure. 

When a patient comes to me with some rectal 
trouble and I find a tumor of any kind, no matter 
whether it be hemorrhoid or some form of benign 
growth, or should there be a fistula, ulceration, or 
.in fact any real abnormal condition of importance, 
I feel that proper treatment is imperative and almost 
as urgent as it would be should a woman come with 
a tumor in her breast. In either case, if left un- 
treated, no harm may result, yet there is always the 
possibility that malignant disease may be started 
with fatal result. 

I do not think it wise or right to frighten people 
into operations and I never do this. If they are told 
bluntly that their piles might turn into cancer, they 
will be needlessly frightened, because they will not 
understand the doctor's real meaning, but if it is ex- 
plained to them that any diseased condition that is 
curable, and that can be cured with but little danger 
to life, should receive attention, as it might be the 



RECTAL CANCER. 311 

means of starting some more serious conditions that 
would not be so easily remedied ; intelligent patients 
will at once see the force of the argument and have 
any diseased condition that may be present at- 
tended to. 

I have had patients write to me stating that they 
had some rectal trouble and wish to make arrange- 
ments to come for treatment. For some reason the 
visit was not made and the treatment postponed for 
several months, and when they did finally come I 
would find a well marked case of carcinoma. Had 
they attended to the matter when they first noticed 
the trouble the disease might have been removed 
with some hope of permanent cure. 

The symptoms of rectal cancer in its early his- 
tory are rather vague and ill defined. The patient 
may be in apparent perfect health and complaining 
of nothing more than a sensation of weight and un- 
easiness in the rectum; there is now no real pain, 
hemorrhage or diarrhea. The patient thinks that he 
has hemorrhoids, although there is no protrusion or 
other evidence of the disease. 

Should the surgeon be consulted at this time by 
a person past middle life, if no other well defined 
disease be discovered, malignant trouble should be 



312 RECTAL DISEASES. 

suspected and the patient carefully watched so that 
an operation may be done at the earliest possible op- 
portunity after a positive diagnosis has been made. 
Many times, even before any serious symptoms ap- 
pear, the finger may detect a point of induration or 
hardness well up in the bowel wall. This hard lump 
is under the mucous membrane in the submucous or 
muscular tissue, is freely movable, and is usually not 
painful on pressure. It is safer to remove it at once, 
but should the patient refuse an operation, it should 
be looked after, and if there should appear any sign 
of an increase in size an operation should be insisted 
upon at once. 

Later, there will be well-defined symptoms of a 
more positive character. These consist in diarrhea, 
which alternates with constipation. This is not due 
thus early to obstruction, but is caused by the less 
movable, fixed condition of the bowel wall. Later, 
as the growth invades the lumen of the gut, more 
obstinate diarrhea and constipation occur, due to ob- 
struction and the irritating action of retained feces. 
There will now be a discharge of a porridge-like sub- 
stance which may contain traces of blood, but this as 
a rule, does not appear until the growth has broken 
down and ulceration commenced. Even as late as 



RECTAL CANCER. 313 

this, if the growth is movable and does not seem to 
be attached to surrounding structures, it may be re- 
moved, with considerable prospect that it will not 
recur. 

After the entire rectum has become involved and 
everything in the pelvis infected with the cancer 
cells, it is simply foolish, in my judgment, to attempt 
a radical cure with any hope of success, even in pro- 
longing life, as, should the patient live through the 
operation, the disease will return before the wound 
has healed. The freshly cut surface offers new areas 
for infection and recurrence is very rapid. 

As these patients first consult the general prac- 
titioner, I wish to enter a plea in their behalf that 
more attention be given them in the earlier stage of 
their disease that more radical measures may be car- 
ried out while there is some hope of success. These 
cases are not very common, but when they do occur 
it is their family doctor to whom they go for advice 
and he is the one to whom they look for relief. If 
he lets valuable time pass, the disease will make such 
progress that the patient's life may be lost, while an 
early diagnosis might have saved it or at least have 
given a year or two longer lease to life. 



CHAPTER XVIII. 

THE REFLEX ACTION OF RECTAL DISEASES 

The Great Nerve Supply in the Rectal Region — Constant 
Irritation — Four Essential Causes of Reflex Action — 
Clinical Cases — General Reflex — Diagnosis— Treatment. 

In the study of diseased conditions of the human 
body it is essential to investigate carefully in order 
to determine whether the subjective symptoms are 
actually located where the patient thinks they are, 
or if the real disease is in some distant organ or 
tissue, and only carried or reflected to the painful or 
disordered part. 

After having made a careful study of rectal dis- 
eases, I feel confid'^nt that many functional disor- 
ders and painful manifestations result therefrom that 
are referred by the patient to other organs or parts 
of the body. 

In this discussion I include the rectum, anus and 
sigmoid flexure, and also the parts surrounding 

314 . 



REFLEX ACTION 315 

them. In studying the anatomy of the p^rts we find 
a greater nerve supply than in almost any other part 
of the body. The principal nerve supply comes from 
the internal pudic, the fourth sacral, and the pos- 
terior sacral. There is also an intimate connection 
with the sympathetic nervous system. Many large 
ganglia are also to be found in this region, thus unit- 
ing the great nervous systems, the ge*' ^ral and the 
sympathetic. 

The blood supply is also very great. The arterial 
supply comes from many sources, thus affording al- 
ways a large amount of blood thrown into the parts, 
while the veins are not so plentiful, and having no 
valves, often allow the parts to become congested. 

This congested condition combined in many cases 
with constipation, and the free use of purgatives, 
especially those of the class to which aloes belong, 
keep the nerve supply in a constant state of irritation 
or hyperactivity. This condition is much more man- 
ifest when there exists an actual lesion, as an ulcer, 
fissure, proctitis, etc. Then it is that we see in many 
cases reflex symptoms manifest. It is a peculiar 
fact that the reflex symptoms manifested are not of 
the same nature as the causes that produced them. 
For example, a rectal abscess may produce symp- 



3i6 RECTAL DISEASES. 

toms of lumbago. Catarrh of the sigmoid is often 
treated for gastric indigestion, etc. 

In order to produce a reflex action there are 
four things essential. 

First, a point of irritation which, in pathological 
cases, may be an ulcer, abscess, foreign body, etc. 

Second, a line of transmission to a nerve center, 
or an afferent nerve fibre. 

Third, the nerve center, which may be the cord 
or a ganglion connecting the general with the sym- 
pathetic nervous system, and which may affect either 
the motor or sensory nervous system. 

Four, a return line or afferent nerve fibre which 
would ordinarily return the effect or result to the 
spot from whence it originated, but in the case of a 
reflected action, would conduct it to some other part 
of the body. 

It is difficult to account for the fact that certain 
effects are caused by a given pathological condition 
in one case, while the same condition in another case 
will cause a different effect. It seems to be ac- 
counted for only on the ground that certain nerve 
centers are at that time in a more exalted state of 
activity than others, and consequently any irritation 
is more easily appreciated. This is often seen in 



REFLEX ACTION 317 

cases where a rectal abscess will, in one case, cause 
spasm of the urethra, and in another lumbago or 
sciatica ; or where a bad case of hemorrhoids with 
prolapse will, in one case, cause vertigo, and in an- 
other cough, loss of flesh, and symptoms of phthisis. 
Yet that these results are seen can be verified by any 
careful observer. 

In a moderately severe case of hemorrhoids that 
came under my care about two years ago, the patient, 
a traveling salesman, was in an extreme state of 
nervous debility, and greatly emaciated. He had a 
worn, despondent expression, and was much dis- 
couraged. An operation effected a complete cure, 
and when I next saw him, some six months later, 
he had not only gained twenty-five pounds in weight, 
but had lost the despondent look and crabbed temper. 
His nervous system was entirely restored to its nor- 
mal condition. 

Matthews, in his work on rectal diseases, de- 
scribes a case that I will outline briefly. A man 
came under his care who had been an invalid for 
about a year. He began by erratic pains, loss of flesh 
and general debility. His nervous system was badly 
deranged. His physician diagnosed his case as ma- 
lignant, but could not tell where the cancerous dis- 



3i8 RECTAL DISEASES. 

ease was located. He rapidly grew worse, until he 
was reported to be in a dying condition, having set- 
tled his business preparatory to his passing to the 
great beyond. Being troubled with a great deal of 
pain in the rectum, together with a persistent diar- 
rhea, Dr. M. was called, who made an examination 
and found an ulcer. The sphincter was divulsed, the 
ulcer scraped and irrigated, and the malignant dis- 
ease disappeared, never to return. 

Dr. Louis Bosher described in detail, before the 
West Virginia Academy of Medicine, a case wdiich 
was diagnosed and treated as intestinal consumption, 
and the patient was reduced to such an extreme state 
of emaciation that death was considered only a mat- 
ter of a few weeks. Almost by accident a rectal ulcer 
was discovered and treated. The patient at once 
began to improve and entirely recovered. 

The three cases just detailed I would classify as 
types of a general reflex action rather than a local- 
ized one ; that is, they have their effect on the entire 
nervous system, or at least on several important cen- 
ters, interfering with the functions of important or- 
gans or glands, or in other indirect ways lowering 
the vitality and power of organs whose normal state 
of functional activity is essential to the life of the 



REFLEX ACTION 319 

body. These cases are just as truly reflex in char- 
acter as the ones that follow, although the pathology 
in the latter was confined to one spot instead of be- 
ing of a more general nature. 

A man about forty years of age was taken with 
severe pain in the lumbar region. This became so 
severe that he had to go to bed. His physician diag- 
nosed his case as one of lumbago, and treated it as 
such. After lying in bed a few days he would be a 
little better and would get around with a cane, which 
would invariably start the pain again. This severe 
pain never left him unless under influence of mor- 
phine. This kept up for about six weeks, until, in 
one of his convalescent periods, he came to my office 
and said that he had a discharge from the rectum 
that kept the parts moist, and made him very un- 
comfortable. 

Upon examination, I found the opening of a 
very small sinus, which led up to an abscess behind 
the rectum. I opened it freely and let out two or 
three ounces of pus. From tliat minute the pain in 
his back left him. I do not know what caused the 
abscess, or why it formed so slowly. Neither did 
either of us think of tl:ere being any connection be- 



320 RECTAL DISEASES. 

Iween the rectal trouble and the back, but the cure 
of one instantly cured the other. 

A case is reported in which a small abscess just 
in front of the coccyx caused an almost unbearable 
neuralgia of the occipital nerve located in one small 
spot. This was treated in almost every way with no 
benefit until the abscess was opened and cleaned, 
when the pain left as if by magic, and did not return. 

These two cases are illustrations of localized re- 
flex action. Although the main features are the 
same in all cases, the last two do not have so general 
an effect as the ones that preceded them. 

In some cases, as the first one mentioned, there 
does not seem to be sufficient lesion to account for 
the serious symptoms present. There seems to be, 
in these cases, a leakage of nerve force, which, like 
the leakage of a steam boiler, by diverting the steam 
from its proper course, weakens the power and low- 
ers the usefulness of the machinery. So in these 
cases, the vital element of nervous force is wasted 
and the power of physical resistance is lessened, thus 
weakening the power of every organ and tissue in 
the body. 

The diagnosis in these cases is as a rule not dif- 
ficult, and is made by exclusion and examination. 



REFLEX ACTION 321 

After the diagnosis is established, the treatment of 
course consists in removing the cause, when the ef- 
fect will go with it. 



CHAPTER XIX. 

RECTAL EXAMINATION FOR LIFE INSURANCE 

Importance of Physical Examination — Maj^o's State- 
ment of Rectal Cancer — Clinical Cancer Cases — Ulcera- 
tion — Symptoms — Cases cited. 

To the physician who wishes to be thorough in 
his examinations for Hfe insurance, there are certain 
cases that are of the geratest importance, especiaUy 
when viewed from the standpoint of the companies' 
interests. 

I refer to the existence of rectal diseases, espe- 
cially cancer, ulceration, syphilis, stricture and fis- 
tula. It is well known to any one who does much 
rectal surgery that nearly all diseases that affect 
these parts are called piles, and w^hen the question is 
asked, ''Have you had piles, fistula, or any disease 
of the rectum?" the applicant will often answer he is 
''slightly troubled with piles." 

His so-called piles may, and often do, consist of 
322 



Examination for Life Insurance. 323 

a discharge of blood or a mixture of mucus, pus, and 
blood, indicating cancer, ulceration, or stricture, but 
the examiner will, in nearly all cases, record the an- 
swer as given, or, at the suggestion of the agent, if 
present, will answer the question in the negative, as 
"it is of no importance and makes the examination 
look bad." 

For the benefit of the company about to assume 
the risk, such cases should be submitted to a careful 
and thorough examination. The importance of 
physical examinations is so great that all companies 
are very careful to secure only competent examiners, 
so that no risk may be assumed below a certain 
physical standard. The lungs, heart, and kidneys 
are examined with great care, while the last four 
inches of the intestinal canal, which is more likely to 
be diseased than any of the others, is entirely 
ignored. 

Coley, in the "Twentieth Century Practice," 
states that "four per cent of all cancers occur in the 
rectum, and Sutton, as reported by Mayo, of Roches- 
ter, says, of one hundred cases of intestinal carci- 
noma, seventy-five will be in the rectum, twenty- 
three in the large intestine, and only two in the 
small intestine." Out of three hundred and fiftv- 



324 RECTAL DISEASES. 

four deaths reported to one of our largest insurance 
companies, I find that two died from cancer of the 
recttim. two from ulceration of the rectum, one 
from constmiption of the bowels, and one from dys- 
enter}'. 

The two last were most likely dtie to ulceration 
or cancer. In addition to the above there were 
eleven deaths due to cancer, whose location is not 
stated. This gives a percentage of not less than two 
deaths per hundred due to rectal cancer. These 
persons' average age was about fort}- years, and 
some of them had taken out their insurance less than 
a year previous to their death. It is only reasonable 
to suppose that in at least a part of the cases the 
disease could have been discovered at the time the 
examination was made. Granting this to be the case, 
justice was not done the company which assumed the 
risks. 

I wish to report a few cases which will illus- 
trate fully my views of this matter. 

]\Ir. \\'.. age thirt}--seven. applied for insurance 
in one of our old line companies. His family history 
was good, with the exception that his mother's 
mother had died of phthisis and one sister had died 
of some trotible following confinement, not satisfac- 



Examination :por Lii^E Insurance. 325 

torily explained, but as she was ill about two months, 
I looked upon her case with suspicion. Mr. W. was 
apparently in perfect health in every way with the 
exception that he ''was troubled a little with piles." 
Upon examining the rectum, I could not find any 
hemorrhoids, or in fact, any well-defined disease 
other than a slight moisture which seemed to come 
from a fistula, but by the most painstaking efforts I 
could not find any fistulous opening. Still, the tis- 
sues around the anus did not look healthy, and I de- 
clined to recommend the risk for a period of three 
months, which would give sufficient time for any 
diseased condition to develop. The agent who solic- 
ited the risk was not satisfied with this, as it caused 
the loss of a good commission to him, so he took the 
applicant to another examiner, who passed him, en- 
tirely ignoring the rectal trouble. In less than three 
months a tubercular fistula made its appearance, and 
in about eighteen months the applicant died of gen- 
eral tuberculosis. 

In speaking of cancer of the rectum, Kelsey, in 
his last work on "Diseases of the Rectum and Pel- 
vis," says : "It is often astonishing to the surgeon to 
meet with an advanced case of scirrhus, in which the 
caliber of the bowel is so nearly occluded as scarcely 



326 RECTAL DISEASES. 

to admit the passage of the finger, and yet in which 
the patient has never had sufficient uneasiness to call 
for a direct rectal examination." 

Dr. ^latthews, in his work on rectal diseases, re- 
lates the following case, which shows the importance 
of an examination: "]\Ir. C, about forty-five years 
old, came to me at the suggestion of his physician 
for an examination of his rectum. He remarked that 
his doctor was not sure that he had any rectal dis- 
ease, nor was he, yet because of the fact that he 
strained at stool and passed a little blood and mucus, 
he thought it best to be examined. Placing him in 
the Sims position, and in a good light, I carefully 
searched the rectum with a speculum, but could find 
no disease. Removing the instrument, I introduced 
my finger, and asked the patient to strain down, 
when I was enabled to explore the gut five or six 
inches. At the end of my finger I detected an in- 
durated spot, which seemed (o extend upward. 

Reasoning by exclusion, I could not imagine any 
other disease than cancer that could cause this hard, 
nodulous, little tumor, located at this spot. Although 
there was no glandular involvement, I was thorough- 
ly of the opinion that this man had incipent cancer. 
He was given treatment by injections, etc., and in a 



Examination for I^if^ Insurance:. 327 

few days his symptoms cleared up, and there was no 
discharge of either blood or mucus, and no straining 
at stool. 

After this he took a long journey of about fifteen 
hundred miles, and upon his return he called at my 
office to say that he had entirely recovered. He had 
a respite from all bad symptoms for a month or six 
weeks. During this interim he applied for a policy 
of ten thousand dollars, passed the examination, no 
attention being paid to the rectum, and was insured. 
After a while his condition grew worse ; a discharge 
of blood and mucus was noticed ; he began to emaci- 
ate ; took on a bad color ; and in less than six months 
perforation took place, and he died — of cancer." 

The next disease of which I wish to speak, is 
ulceration. When we consider the following symp- 
toms of the disease, it is readily seen that an appli- 
cant who said that he was troubled with piles would 
be passed without question by the average examiner, 
if the application was made before the disease had 
progressed too far. The first thing noticed by the 
patient in this disease is a diarrhea, which is worse 
in the morning. Often there will be two or three 
passages before breakfast, and but little is passed, 
except mucus, or, as the patient describes it, ''like 



328 RECTAL DISEASES. 

the white of an egg" ; he may also complain of tenes- 
mus, and say that "there seems to still be something 
more to pass," but he is unable to relieve himself of 
it. Probably after breakfast he will have a normal 
movement, and go through the day with but little 
inconvenience ; later he will find the passages more 
frequent, and often smeared with blood. This may 
last for months, gradually getting worse ; more blood 
and pus will be seen in the stools, and they will often 
have a coffee-ground appearance, as is seen in ulcer- 
ation of the stomach. 

This condition is a very serious one, and will end 
in stricture, requiring the gravest surgical proced- 
ures to effect a cure, and in a majority of instances 
death is the result. These cases are by no means 
rare, and nothing in the whole list of human ail- 
ments requires more skill to effect a cure. I devote 
this much space to symptoms to show that while the 
disease is a serious one, it can be diagnosed in its 
early stages, and the company to whom application 
is made prevented from accepting a risk that will 
soon die on their hands. 

As illustrating the above condition, I would cite 
the following case. Mr. B., age about forty, con- 
sulted me because he was "troubled with piles." He 



Examination i^or Lii^E Insurance. 329 

stated that he felt a little pain of a dull, burning 
character, and had some discharge of "'white stuff," 
and occasionally the movements were "streaked with 
blood." It did not bother him much, but he wished 
to see what I thought about it. He did not think it 
of enough importance to submit to an examination, 
even after I had explained to him the probable cause 
and result of his disease. He consulted another 
physician, who told him that it was "nothing that 
amounted to anything," and gave him some medi- 
cine to take which would "make matters all right in 
a few days." At this time Mr. B. was in good 
health, except for the trouble spoken of, and would 
have been accepted by almost any company to whom 
he might have applied for insurance, as a majority 
of the examiners w^ould have entirely ignored the 
rectal trouble. 

Shortly after consulting me he moved to another 
town, and I did not see him for several months ; then 
one day he came into my office, and was so pale and 
emaciated that I scarcely knew him ; he told me that 
he had lost fifty pounds in weight, and that his bow- 
els were moving from ten to twenty times daily ; liis 
physician, he said, was treating him for intestinal 
consumption. He died soon after this. 



330 RECTAL DISEASES. 

There are many cases of chronic proctitis, or 
rectal catarrh that are easily recognized if the proper 
methods of diagnosis are adopted, and which usually 
yield promptly to treatment. These affections are 
most often found among men of middle age, espe- 
cially those whose occupations are largely out of 
doors, where they are exposed to sudden changes of 
temperature. This condition is largely responsible 
for the considerable number of cases of chronic diar- 
rhea among our old soldiers, and is directly due to 
the exposure and hardships incident to camp-life, 
especially sitting and sleeping on cold, damp ground. 

Many of these people die after only a few years 
of suffering from this disease or from some other 
comparatively trivial affection complicating it ; again 
it may assume an ulcerative form and result in 
stricture and death. There is a long period of time 
in most of these cases, during which the disease is 
easily recognized, but it may not present symptoms 
sufficiently well marked to prevent an applicant from 
passing a satisfactory examination. 

I believe all who will give this matter careful at- 
tention will agree with me that the conditions out- 
lined above are very important and deserve the seri- 
ous and careful attention of all examiners who have 



Examination p'or Lii^E Insurance). 331 

at heart the best interests of the companies they rep- 
resent. 

I do not wish to be understood as advocating a 
careful rectal examination in all cases, but only in 
those where it seems indicated. 



CHAPTER XX. 

COLOSTOMY: TECHNIQUE OF OPERATION AND 
RESULTS 

Changing the course of Fecal Current — Two General Indi- 
cations — To Divert Temporarily — ^Permanent Artificial 
Anus — The Operation — The After Treatment. 

The question of changing the course of the fecal 
current in inoperable affections of the lower bowel 
and causing it to flow from the body in some other 
place than that intended by nature is one that has 
been before the profession from the earliest recorded 
history of surgery. Many think that it leaves the 
patient in a condition pitiable in the extreme and dis- 
gusting to himself as wxll as to those around him, 
,and that death would be preferable. As the opera- 
tion was formerly done this was true, but modern 
surgery has so improved the technique, and nature's 
method of closing the external orifice by a sphincter 
muscle is so closely simulated, that many of the 
unpleasant features are eliminated. 

332 



COLOSTOMY. 333 

There are two general indications for doing this 
operation. The first is to divert the fecal current 
from the lower bowel temporarily until operative or 
other measures have cured the disease below, when 
the artificial opening is closed and the natural chan- 
nel again established. The other is to make a per- 
manent artificial anus, because of inoperable disease 
or malformation below the opening. 

Until within recent years a temporary opening 
was seldom made, but if an opening was made the 
patient was expected to carry it with him to the 
grave. At the present time an opening is made 
more often than should be done, and for insufficient 
reasons. If such an operation seems indicated, all 
sides of the matter should have careful considera- 
tion, and it should never be done except for good 
reasons, as there is considerable danger in making 
the opening and even more in closing it. Wheeler 
estimated the mortality at 25 per cent, but this was 
before the days of aseptic surgery. It should also be 
remembered that many patients are almost ready to 
die when they come for operation. In perfectly 
healthy subjects, if proper precautions are observed, 
there should be a very small mortality, probably not 
more than i or 2 per cent. 



334 RECTAL DISEASES. 

While the operation for either temporary or per- 
manent colostomy may not be considered as major 
surgery, they both require an attention to detail 
and technique of the most painstaking character. 
Nothing that I can think of will cause more suffer- 
ing and mental agony during the remaining life of 
the patient than a poorly done colostomy. 

I will speak only of the operation as done in the 
left inguinal region, as this is the one most often 
done. In doing the operation, for temporary pur- 
poses, make an incision about two inches long and 
one-half inches above the ant. sup. spinous process, 
crossing an imaginary line drawn from the process 
to the umbilicus, about one-third above and two- 
thirds below the above line. After going through 
the skin and superficial -fascia, the fibres of the m- 
ternal and external oblique are separated but not 
cut. After dividing the peritoneum it is brought 
out and attached to the skin with fine catgut. Next, 
the colon is searched for and usually found with 
but little trouble. Here an important point is to 
be observed, and that is, to draw the upper portion 
of the colon down until a short mesentery is found, 
letting the redundant portion pass back into the ab- 
domen through the lower part of the incision, If 



COLOSTOMY. 



335 



this is not done, there is sure to be a prolapse of 
the upper part of the gut, which wiU be very annoy- 
ing to the patient. The next important point is to 
get a good spur; that is, to get the bowel out far 
enough so that all the fecal matter coming from 
above will pass out of the bowel and none of it go 
into the lower portion. 

As this is to be a temporary opening, it is im- 




Fig. 64. Inguinal Colostomy. (Bodine). 
portant that some arrangement be made so that it 
may be closed easily when it is thought best to do 
so. In order to do this the bowel should be pulled 
out and the two apposing edges united by catgut lig- 
atures for two and a half to three inches to prevent 
coils of small intestines or other structures getting 



336 RECTAL DISEASES 

between and being clasped in the clamp that is used 
to divide the walls later. This particular part of 
the operation should be credited to Bodine, who 
originated it. 

The bowel is now dropped back into the abdo- 
men until the posterior w^all is level with the skin. 
A glass rod is forced through the mesentery just 
beneath the bowel wall, with the ends resting on the 
abdom.en at each side of the opening to hold the 
bowel out sufficiently to make a good spur. The 
skin and bowel wall are now^ carefully united with 
silk all the way around. If this is not done, other 
coils of intestine may be forced out by the side of 
the one intended to be out. 

If the necessity for opening the bowel is not urg- 
ent, it should be left for forty-eight hours until ad- 
hesions have formed so that the peritoneum may not 
become infected. When the opening is made co- 
caine may be used and the bowel pared off about 
one-half inch above the skin, leaving a typical 
double-barreled opening. 

When it is desired to divert the fecal current to 
its natural channel again the three-inch septum may 
be cut through by applying an ordinary long- jawed 
forceps leaving it on until it cuts itself loose 



COLOSTOMY. 337 

Should the external opening not close entirely, 
a slight plastic operation may be done under cocaine 
anaesthesia to close it. 

In case the artificial opening is to be permanent, 
a different method should be employed. The in- 
cision should be made about an inch nearer the um- 
bilicus than in the other case. The peritoneum is 




Fig. 65. Enterotomy after Colostomy. (Bodine). 
not brought out and stitched to the skin. The bowel 
is brought out and pulled down until a short mesen- 
tery is found and then cut in two, the lower end of 
the opening closed and dropped back into the abdo- 
men. We now have nothing but the upper end 
to deal with. An incision is now made the same 
length as the first one an inch below and parallel 



338 RECTAL DISEASES. 

with it, extending through the skin and superficial 
fascia only. The bridge of tissue separating the 
two incisions is now undermined between the super- 
ficial fascia and the external oblique and the bowel 
drawn through the tunnel thus made and stitched tr 
the edge of the opening. The upper opening is now 
closed down to where the bowel makes its turn into 
the tunnel. 

Wq now have not only the fibers of the two 
oblique muscles closing the bowel, but we have also 
the bridge of skin shutting off the end and acting 
as a sphincter muscle. This will allow but very lit- 
tle, if any, leakage and considerable force must be 
applied by the abdominal muscles to cause fecal mat- 
ter to be expelled. 

This is nearly the same operation as described 
by Tuttle in his new work on rectal surgery, but 
varies in some of the details, especially in dropping 
the lower end of the bowel back into the abdomen. 
I believe that the risk incurred in dividing the bowel 
and dropping it back is so small compared with 
benefits derived that it is better that it be done. 

With the improved methods of treating malig- 
nant and syphilitic rectal diseases, together with im- 
proved methods of making an early diagnosis, the 



COLOSTOMY. 



339 



indications for doing colostomy operations are less 
than formerly existed. It is of course an operation 
to be avoided if possible. At the very best it is an 
operation that has a very depressing mental effect, 
and many patients suffer very severely because of 
the unnatural opening, even though from a mechan- 
ical and surgical standpoint it works to perfection. 
Yet in spite of this the patient's life may often be 




Fig. 6 6. Showing how the bowel passes between the 
superficial fascia and external oblique muscle for about 
an inch before emerging through the skin. 

prolonged and much physical suffering avoided by 
a properly done colostomy. 



340 RECTAL DISEASES. 

They soon learn how best to care for themselves, 
and by the use of snugly fitted bandages, or in some 
cases steel springs in the form of a truss, they have 
but little trouble and pass the remainder of their 
da3^s in comparative comfort. It will, beyond doubt, 
prolong life, in some cases a year or more, and by 
relieving pain, checking diarrhoea and hemorrhage, 
and preventing the almost complete obstruction that 
occurs in nearly all of these cases, the patient is more 
than repaid for the inconvenience and the care he 
is obliged to give the unnatural opening. 

I know of no more helpless position in which 
to place a surgeon than to have to care for a rectal 
cancer in its last stages unless he be allowed to seek 
relief, not only for the patient, but for himself, in 
a colostomy. 



CHAPTER XXI 

LOCAL ANESTHESIA 

Methods of rendering Tissues Nonsensitive — Chloried 
Spray — Cocaine — Sterile Water Injection — Strength of 
Solutions Used — Electricity — Many Reasons for Oper- 
ating under local Anesthesia. 

As this work deals almost entirely with local 
anesthesia, and as no doubt many think that some 
of the operations described cannot be done except 
under the influences of general anesthetics, I wish 
to say a few words upon this subject. 

There are several different means by which the 
tissues may be rendered nonsensitive. The quickest 
and easiest is by the use of the ethyl chloride spray 
by which the parts are frozen. This, however, 
causes so much pain when the tissues begin to thaw 
that it is not very satisfactory, especially if the mu- 
cous membrane is involved as it causes such a burn- 
ing sensation that the patient would prefer to stand 
the pain of the operation rather than the freezing 
and thawing of the tissues. 

341 



342 RECTAL DISEASES. 

It has been recommended by good authority to 
give the patient a big drink of whisky fifteen or 
twenty minutes before operating, to be followed five 
minutes before the operation by one-fourth grain of 
morphine sulph. This will reduce the pain to a 
minimum and with some patients is very satisfac- 
tory but the moral effect is bad and you may unwti- 
tingly start your patient on the road to a drunkard's 
grave or restart one who is making a serious effort 
to reform. 

I have used cocaine or eucaine "B" in my prac- 
tice for several years, and if properly managed 
think them perfectly safe. Cocaine, I think, is the 
better anesthetic, but is more toxic, still if not much 
is needed in a given case I always use it as it seems to 
have a better effect. If the operation is quite exten- 
sive I use the eucaine ''B." 

There has recently been going the rounds of the 
medical press extracts from a paper on the use of 
sterile water injected into the tissues to produce 
freedom from pain in rectal surgery. This idea is 
not new, as I recommended it in the first edition of 
this book in 1901 and it had been used by me for 
ten years prior to this. It is not suitable to all cases 
but only such operations as may be in tissue that can 



LOCAL ANESTHESIA. 343 

be made tense by the distension of the water and 
kept so for several minutes. 

If the injection be made in loose connective tis- 
sue where the water spreads rapidly over a large 
field it will have but little effect, and, as the small 
amount of cocaine needed to produce the required 
effect is absolutely harmless it should be used. 

I have used cocaine and eucaine in probably a 
thousand cases and have never seen any toxic effect 
that was at all alarming. During the past year I 
have been adding a few drops of adrenlin solution 
and find that it is beneficial in driving out the blood 
and holding the cocaine in contact with the tissues 
for a longer time. 

I think most operators use too strong a solution. 
One says 16 per cent. I never use more than four 
per cent where it is injected and 10 per cent where 
it is applied locally to mucous membrane, and many 
times do not use more than half the above strength. 
I would prefer to inject thirty drops of a 2 per cent 
solution rather than fifteen drops of a 4 per cent 
solution. If the incision is made before the fluid 
has had time to all absorb, a large part of it will 
run out with the blood, and of course lessen the 
systematic effect, thirty drops of a 2 per cent solu- 



344 RECTAL DISEASES. 

tion may safely be injected into the tissues. This 
would be only a fraction more than a half grain, and 
is more than is actually needed in most cases. If the 
eucaine "B" is used, fully twice the above strength 
may be employed. Ten drops of a 2 per cent solu- 
tion injected into a prolapsed pile of medium size 
will render it absolutely devoid of sensation so that 
it may be handled in any way desired. 

The Schleich formula made in tablets is very 
convenient. Each tablet contains, cocaine i gr., 
morphine Yi gr., sodium chloride 2 gr. 

One tablet added to sixty drops of water makes 
a solution of not quite two per cent of cocaine. Only 
fresh solutions should be used. 

The temperament of the patient has much to do 
with the success of the procedure. Some nervous 
persons are very easily frightened and the sight of 
the surgeon and the instruments will make them so 
restless and uneasy that it is impossible to do any- 
thing with them. On the other hand it is often 
the fault of the surgeon. If he is nervous and 
awkward and goes about his work as though he did 
not know what he was trying to do he cannot help 
but impart the same feeling to his patient. 

I have recently been experimenting with electric- 



LOCAL ANESTHESIA. 345 

ity to drive cocaine into the tissues by cataphoresis 
as suggested in the following, taken from the Lan- 
cet : — "The method outlined is as follows: A solu- 
tion consisting of adrenalin chloride two drachms, 
cocaine five grains and water one-half ounce is pre- 
pared. Lint is folded into a pad of four layers, 
soaked in the solution, and placed under a positive 
electrode. A large negative electrode is applied else- 
where, and a current of from fifteen to thirty mili- 
ampres is slowly induced and run for a space of 
from five to fifteen minutes. The surface may then 
be washed with ether, and superficial operations per- 
formed painlessly and without the loss of blood." 

I have not had sufficient experience with this 
method to know just what there is in it, but believe 
that it will prove of great value in many cases. 

I had made a copper rectal electrode ( see cut ' /n 
page no.) which when wrapped with gauze soaked 
in cocaine solution is introduced into the bowel and 
the positive cord attached. The negative pole is 
applied elsewhere and a current of about fifteen mili- 
amperes turned on. 

I hope by this method to be able to so anes- 
thetize the sphincter muscles that they may be com- 
pletely divulsed in the office. If this can be done, 



346 RECTAL DISEASES. 

much of the difficuhies of doing rectal surgery with- 
out general anesthetics, will be overcome. 

There are many reasons why all operations pos- 
sible should be done under local anesthetics. 

1st. It removes all danger from death due to 
the anesthetic. 

2nd. It avoids the danger of post operative 
complications and the effect on some of the internal 
organs from chloroform or ether. 

3rd. There is no period of unconsciousness, 
which seems so horrible to the friends and which is 
often followed by severe nausea and vomiting. 

4th. ^lany persons who are conscious will ren- 
der valuable assistance to the operator. 

5th. ]\Iany will come for operations who would, 
not do so if they thought they had to take chloro- 
form or ether. 

As has been stated before, this work requires at- 
tention to details, tact, judgment, gentleness,, and 
courage. A\hthout these no physician will meet with 
a great measure of success in any branch of his call- 
ing: with them he will surely prosper, both profes- 
sionally and financially. 

In closing. I wish to quote an editorial extract 
from the International Journal of Surgery, on local 



LOCAL ANESTHESIA. 347 

anesthesia, taken from the issue of February, 1899. 

• ''It is remarkable how unimportant a place local 
anesthesia still occupies in surgery. It is an indis- 
putable fact that complete anesthesia is still, and 
will always remain, a matter of dread to patients, 
and that surgeons do not make any very strenuous 
endeavors to avoid it when they could possibly do 
without it. The most profitable work for surgeons 
is often connected with the painless treatment of 
common affections, such as piles, in people who 
would subject themselves to ordinary operative 
measures were it not for the fear of anaesthesia. 
In chlori.de of ethyl ('Kelene') and the subcutaneous 
employment of cocaine and eucaine" (better still, by 
means of the new Cocaine-Kelene Autospray,) "we 
have means that are not really half studied out, and 
which deserve more careful consideration than they 
have yet obtained. The writer has operated for 
piles and fistula, has removed the clavicle with 
Schleich's infiltration anesthesia and chloride of 
ethyl ('Kelene. ). The use of the latter, prior to the 
inserting of the hypodermic needle, is often of ad- 
vantage, as its insertion, in cases of ingrowing nails 
and infected fingers, is often almost as painful as 
the operation itself. The ophthalmologists are near- 



348 RECTAL DISEASES. 

ly the only ones who tise local anesthesia to the full 
extent of its possibilities, and we expect to see prac- 
titioners of other branches of surgery in the near fu- 
ture, more eager to extend the scope of local anes- 
thesia, both for the welfare of the patients and for 
the increased facility with which they will find tha^ 
patients will submit to necessary procedures." 



INDEX 



Abscess, 142 

after treatment of, 157 

etiology of, 143-144-145 

examination for, 155 

ischio-rectal, 146 

opening of, 143 

pelvi-rectal, 145-149 

seat of, 142 

subcutaneous, 146 

sub mucous, 148 

symptoms and diagnosis, 
150 

treatment of, 157 
Absence of anus, 291 
Acute proctitis, 242 
Anus, absence of, 291 

artificial, 290 
Artificial anus, 290 
Acute constipation, 67 
Adenoma, 230 
Adeno-papilloma, 232 
After treatment of abscess 
157 

Colostomy, 337 

fistula, 179 

ulcer, 190 
Alimentary constipation, 68 
Alimentation, methods of, 88 

rectal, 87-90 
Anatomical cause of hemorr- 
hoids, 94-95 
Anal canal, 58 
Anatomy, 48 

Anesthetics in fecal impac- 
tion, 86 



Anesthesia, local, 341 

Angioma, 235 

Ani levator, 50 

Ani muscle, 66 

Ani sphincter, 49 

Appliances, 28 

Arteries, 59-60 

Atonic constipation, 74 

Boas' diet list, 76 

Bones, 48 

Bowels, 

current of, 89 

training of, 70 
Bacillus coli communis, 144 
Blind external fistula, 160 

internal fistula, 160-164 
Cachexia, 37 
Canal, anal, 58 
Cancer, rectal, 298 

prevention of, 308-312 
Capillary hemorrhoids, 96 
Cataphoresis, 345 
Catarrh, intestinal, 69 
Catarrhal conditions, 31 
Cathartics, 81 
Cause of, 

fecal impaction, 84 

hemorrhoids, 92 

prolapse, 207 

pelvi-rectal abscess, 150 

proctitis and sigmoiditis, 
237 
Cavities of pelvis, 49 
Chronic proctitis, 71 

treatment of, 239-240-241 



349 



350 



INDEX 



Clamp and cautery opera- 
tion, 135-136 
Classification of ulcers, 193 
Clinical cases, 116-117-278- 

324-325 328 
Colon, irrigation of, 201 
Colostomy, 296-332 
Columns of Morgagni, 58 
Complete fistula, 159-165-166- 
180 

treatment of, 170 
Complex fistula, 160 
Congenital malformation, 289 
Constipation, 67-68-74-72-75- 
76-77-82-106 

acute, 67 

alimentary, 68 

atonic, 74 

chronic, 67 

constitutional symptoms, 
34-74 

diagnosis of, 75 

etiology of, 68 

in hemorrhoids, 106 

in pregnancy, 72 

mechanical treatment of, 
77 

spastic, 74 

specific causes of, 67 

treatment of, 76-82 
Copper electrode, 110 
Current of the bowel, 89 
Cystoma, 233-234 
Defecation, 70 
Description of puritus, ani, 

270 
Diagnosing by examination, 

31 
Diagnosis, 28-31 

of constipation, 75 

fecal impaction, 84 

fistula, 161 

methods of, 34 

prolapse, 208 

rectal cancer, 300 

ulcer, 183-184 
Diet list, Boas, 76 
Diet in treatment of hem- 



orrhoids, 105 
Dilatation, 108 
Dilators, 109 
Diarrhoea, 36 
Discharge, 36 

Diseases, complication of, 33- 
34 

venereal, 32 
Divulshion, 192 
Duodenum, growths in, 226 
Electrode, 110 
Electrolysis, 140-261 
Electric rectal irrigator, 78 
Electric treatment, 78-79 
Enchondroma, 234 
Etiology of abscess, 143-144- 
145 

constipation, 69 

fistula, 160 

hemorrhoids, 92 
Examination at birth, 289 
Examination for abscess, 155 

preparation for, 29 

instrumental, 39 

physical, 37 

positions for, _ 38 
External hemorrhoids, 96 
External sphincter muscle, 32 
Exploratory laparotomy, 43 
Fecal impaction, 83-266 

anesthetics in, 83 

causes of, 83 

diagnosis of, 84 , 

symptoms of, 84 

treatment of, 84 
Feces, normal, 69 
Fibroma, 231 
Fibroid tumors, 229 
Fistula, 159 

blind, external, 162 

internal, 160-164 

complete, 165-180 

complex, 160 

diagnosis of, 161 

etiology of, 161 

incomplete, 159-160 

internal incomplete, 168 

horse shoe, 66 



INDEX 



351 



location of, 161 

symptoms of, 161 

treatment of, 167-168-171- 
172 
Foreign bodies, 150-266-269 
Fossa ischio rectal, 65 
Galvano cautery, 136 
Gant's clamp, 140 
Gastric juice, effect of, 144 
Gradual dilation, 190 
Grooved director, 178 
Growths in duodenum, 22 6 

non-malignant, 226 

texture of, 228 
Gun shot wounds, 266 
Haematoma, 144 
Hemorrhage, 35-36-229-230 
Hemorrhoids, 91-96 

a cause of rectal cancer, 
307 

anatomical cause of, 94-95 

capillary, 96 

cause of, 92-93 

classification of, 95 

cutaneous, 96 

diet in, 105 

etiology of, 92 

heredity, 92 

internal, 96 

palliative treatment of, 105 

symptoms of, 96 

thrombotic, 96 

treatment of, 104 

venous, 96 
Horse shoe fistula, 66-73-178- 

179 
Hypertrophy of rectal valves. 

73 
Incision treatment of fistula, 

175 
Incomplete external fistula, 
162 

prolapse of rectum, 206-207- 
214 

internal fistula, 163 

fistula, 159 



Inferior hemorrhoidal artery. 

60 
Inferior hemorrhoidal vein, 

63 
Infective method. 111 
Instrumental examination, 39 
Instruments required, 30-262 
Irrigation of the colon, 201 
Irritable ulcer or fissure, 

183 
Ischio-rectal abscess, 145-147 

fossa, 65 
Intestinal catarrh, 69 
Internal hemorrhoids, 96 

incomplete fistula, 168 

sphincter, 50 
Lack of fluids, 69 
Laparotomy, exploratory, 43 
Lavage, rectal, 78 
Law's pneumatic procto- 
scope, 44 
Laxative formulas, 107 
Lead colic, 74 
Levator ani muscle, 50-51 
Ligature operation, 130-131 
Light, 30 
Lipoma, 233 
Local anesthesia, 341 
Location of fistula, 161 
Malformation, congenital, 

289 
Malignant stricture, 256 
Mastication, 69 
Mechanical cause of consti- 
pation, 72 

treatment of constipation, 
77 
Membrane, mucous, 58 
Methods of alim^entation, 88 
Methods of diagnosis, 34 
Method of injection, 88 
Method of operating by injec- 
tion, 118 
Middle hemorrhoidal artery, 
60 

vein, 60 
Mineral water, 81 



352 



INDEX 



Morgagni, columns of, 58 

valves of, 59 
Muscular coat of rectum, 57 
Muscles, 49 
Muscle, coccygeus, 52 

corrugator cutis-ani, 66 

levator ani, 50-51 

external sphincter, 22 
Mucous discharge, 36 
Mucous membrane, 58 
Nervousness, 37 
Nerves, 63 

Nerve supply of perineal, 64 
Non-malignant growths, 22 6 
Non-malignant stricture, 256 
Normal feces, 69 
Notes on injection method, 

125 
Notched clamp operation, 129 
Opening of abscess, 143 
Operation by ligature, 130 
Operating table, description 

of, 130 
Operation with notched 

clamp, 129 
O'Neill's rectal speculum, 124 
Orthoform, 187 
Pain, 73 
Pain absence of, 229 

character of, 35 
Palliative treatment of fis- 
tula, 170-171 
Palliative treatment of hem- 
orrhoids, 105 
Papilloma, 232 
Paralysis, 72 

Patient, position of, 38-88 
Patient, preparation of, 38 
Pelvic-rectal abscess, 145-149- 
151-153 

after treatment, 157-158 

difficulty of diagnosis, 154 
Pelvic bones, 48 
Pelvic cavities, 49 , 

■cellulitis, 154 
Perineum, 64-66-69 
Perinei transversus, 53 
Perineal nerve supply, 64 



Physical examination, 37 
Physiology of defecation, 70 
Pile pipe, 196 
Polypi, rectal, 227 

treatment of, 235 
Position of patient, 38-88-118 
Positions for examination, 38 
Pregnancy in constipation, 72 
Preparation of patient, 38- 

130-131-176 
Proctitis and sigmoiditis, 

cause of, 237 
Proctitis, chronic, 71 
Prolapse of rectum, 206-209- 
21-217-218 
cause of, 2 07-210 

complete, 206-209 

diagnosis, 208 

incomplete, 206 

symptoms of, 208 

treatm_ent of, 213-225 
Proctoscope, Law's pneumat- 
ic, 44 
Protrusion at stool, 35 
Pruritus ani, 72 

description of, 270 

treatment of, 277 

Roentgen rays in treat- 
ment of, 287 
Pus, 36-142 

Quantity of rectal alimenta- 
tion, 90 
Rectal alimentation, 87 

material for, 90 

quantity of, 90 
Rectal cancer, 298-307 

diagnosis of, 300 

prevention of, 308 

symptoms of, 299 

treatment of, 3 03 

catarrh, 330 

examination for life insur- 
ance, 322 

lavage, 78 

muscles, 49 

polypi, 227 

prolapse, 209-211-217-218 

ulcers, 192-193-194 



INDEX 



353 



treatment of, 194-307 
Rectum, anatomy of, 48-49 

description of, 53-54-55 

serous coat of, 57 

structure of, 57 

sub-mucous coat of, 57 
Roentgen rays in treatment 

of Pruritus, 287 
Rodent ulcer, 196 
Seat of abscess, 142 
Serous coat of rectum, 57 
Sigmoid speculum, 46 
Sigmoid, ulceration of, 197- 

198 
Shallow ulcer, 274 
Slide speculum, 121 , 
Spastic constipation, 74 
Spasmodic stricture, 248 
Sphincter, internal, 50 
Speculum, sigmoid, 41 
Spinal nerves, 63 
Sponge and cotton holder, 

194 
Spontaneous cure, 236 
Strictures, 37-73-290 

non-malignant, 255 

malignant, 256 

spasmodic, 248 

traumatic, 249 

tubercular, 249 , 

tubular, 259 

venereal, 251 
Structure of rectum, 57 
Subjective symptoms, 34 
Sub-mucous abscess, 145, 

148-149-157 
Sub-cutaneous or marginal 
abscess, 145 
Sub-mucous or blind internal 

fistula, 173 
Sub-mucous coat of rectum, 

57 

Superior hemorrhoidal ar- 
tery, 59 
Superior hemorrhoidal vein 

61 
Suppositories, 187 
Syphilitic condylomata, 239 



Symptoms of abscess, 150 

fecal impaction, 84 

fistula, 161 

hemorrhoids, 96 

pelvi-rectal abscess, 150 

pruritus, 276 

rectal ulcer, 184-193 

rectal cancer, 298 

subjective, 34 
Sweet oil, injections of, 108 
Technique of Tuttle's opera- 
tion, 221 
Technique of Colostomy, 332 
Technique of Roentgen rays, 

287 
Teratoma, 233 
Texture of growths, 228 
Third stage of hemorrhoidal 

formation, 114 
Thorough examination, 75 
Thrombotic hemorrhoids, 96 

etiology, 9 9 

treatment of, 102 
Training of bowels, 70 
Traumatism, 238 
Traumatic stricture, 249 
T bandage, 109 
T forceps, 133 
Thiosiamen, 261 
Treatment of abscess, 157 

absence of anus, 292 

acute proctitis, 242 

chronic proctitis, 243 

constipation, 76 

cutaneous hemorrhoids, 104 

capillary hemorrhoids, 101 

prolapse, 170-217 

polypi, 235 

pelvi-rectal abscess, 155 

ulcers, 184, 186 

rectal cancer, 303 

wounds, 267 
Tuttle's operation, 219 
Ulcer, 183 

diagnosis of, 184 

divulsion of, 192 

gradual dilation, 191 

operating by incision, 188 



354 



INDEX 



rectal, 193 

symptoms of, 184 

treatment, 184 
Ulceration, 183-327 

of sigmoid, 197-198 

symptoms, 327 , 

Upward current, 89 
Unnatural discharge, 273 
Varieties of abscess, 145 
Various methods of cure, 
Valves of Morgagni, 59 



126 



Vegetable parasite, 280 
Veins, inferior hemorrhoidal, 
63 

middle, 63 

rectal region, 61 

superior hemorrhoidal, 61 
Venous hemorrhoids, 96 
Vertical section of simple 

adenoid, 231 
Vibrator, 77 
Wounds, 265 



m 16 ms 



